Provider Demographics
NPI:1689711913
Name:BADGER, PAMELA MCNEILL (MS, MFT)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:MCNEILL
Last Name:BADGER
Suffix:
Gender:F
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9105 AVOCADO ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-3303
Mailing Address - Country:US
Mailing Address - Phone:619-589-1456
Mailing Address - Fax:
Practice Address - Street 1:3340 KEMPER ST
Practice Address - Street 2:STE 105
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4906
Practice Address - Country:US
Practice Address - Phone:619-523-3812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 18715106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37378100Medicaid