Provider Demographics
NPI:1598938417
Name:GRISHAM, PAMELA CAROLE (MA LPC 11838)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:CAROLE
Last Name:GRISHAM
Suffix:
Gender:F
Credentials:MA LPC 11838
Other - Prefix:MS
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:GRISHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA LPC LMFT NCC
Mailing Address - Street 1:PO BOX 2774
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76099
Mailing Address - Country:US
Mailing Address - Phone:817-691-7898
Mailing Address - Fax:817-267-7036
Practice Address - Street 1:2012 SHADYBROOK
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021
Practice Address - Country:US
Practice Address - Phone:817-691-7898
Practice Address - Fax:817-267-7036
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41171101Y00000X
101YA0400X, 101YM0800X, 101YP1600X
TX11838101YP2500X
TX4005106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist