Provider Demographics
NPI:1730656745
Name:BANKS, PAMELA PEGRAM (LPC, CSAC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:PEGRAM
Last Name:BANKS
Suffix:
Gender:F
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 COVINGTON RD
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2714
Mailing Address - Country:US
Mailing Address - Phone:804-387-3818
Mailing Address - Fax:
Practice Address - Street 1:1116 COVINGTON RD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2714
Practice Address - Country:US
Practice Address - Phone:804-387-3818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-28
Last Update Date:2018-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1215061101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1215061Medicaid