Provider Demographics
NPI:1568559854
Name:WILSON, PAMELA LYNN
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:LYNN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, ACSW, RN
Mailing Address - Street 1:4010 DUPONT CIR
Mailing Address - Street 2:SUITE 309 A
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4812
Mailing Address - Country:US
Mailing Address - Phone:502-417-9291
Mailing Address - Fax:
Practice Address - Street 1:4010 DUPONT CIR
Practice Address - Street 2:SUITE 309 A
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4812
Practice Address - Country:US
Practice Address - Phone:502-417-9291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-12431041C0700X
IN34003932A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN135270Medicare ID - Type Unspecified