Provider Demographics
NPI:1568549343
Name:GUNDLACH, PAMELA PREBLE (M A)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:PREBLE
Last Name:GUNDLACH
Suffix:
Gender:F
Credentials:M A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 SAINT PAUL ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4689
Mailing Address - Country:US
Mailing Address - Phone:802-651-7805
Mailing Address - Fax:802-865-0534
Practice Address - Street 1:187 SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4689
Practice Address - Country:US
Practice Address - Phone:802-651-7805
Practice Address - Fax:802-865-0534
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT684103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006531Medicaid
VT1006531Medicaid