Provider Demographics
NPI:1548216955
Name:WISE ROMERO, PAMELA (PHD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WISE ROMERO
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:PO BOX 2997
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-2997
Mailing Address - Country:US
Mailing Address - Phone:970-247-4589
Mailing Address - Fax:
Practice Address - Street 1:281 SAWYER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-3409
Practice Address - Country:US
Practice Address - Phone:970-259-2162
Practice Address - Fax:970-247-0455
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2481103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COR71626Medicare UPIN
CO541198Medicare ID - Type Unspecified