Provider Demographics
NPI:1720028640
Name:REYNOLDS, PAMELA K (CADC III CC5G)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:K
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:CADC III CC5G
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 WEST AVENUE SOUTH
Mailing Address - Street 2:ATTN PHYSICIAN SERVICES
Mailing Address - City:LACROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601
Mailing Address - Country:US
Mailing Address - Phone:608-791-4156
Mailing Address - Fax:608-791-9898
Practice Address - Street 1:1005 JACKSON STREET
Practice Address - Street 2:
Practice Address - City:LACROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601
Practice Address - Country:US
Practice Address - Phone:608-791-6147
Practice Address - Fax:608-791-9511
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1305101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39365500Medicaid