Provider Demographics
NPI:1508297482
Name:PANGBURN, PAUL DAVID JR (LCSW)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DAVID
Last Name:PANGBURN
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 RICKS CIR
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:19015-1426
Mailing Address - Country:US
Mailing Address - Phone:610-876-3806
Mailing Address - Fax:
Practice Address - Street 1:712 RICKS CIR
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:PA
Practice Address - Zip Code:19015-1426
Practice Address - Country:US
Practice Address - Phone:610-876-3806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0179181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical