Provider Demographics
NPI:1518923226
Name:WILKISON, PAMELA CAROL (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:CAROL
Last Name:WILKISON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 HOMESTEAD RD.
Mailing Address - Street 2:SUITE 40
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098
Mailing Address - Country:US
Mailing Address - Phone:435-901-4307
Mailing Address - Fax:
Practice Address - Street 1:2700 HOMESTEAD RD.
Practice Address - Street 2:SUITE 40
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098
Practice Address - Country:US
Practice Address - Phone:435-901-4307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2643712501103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$002Medicaid