Provider Demographics
NPI:1750029757
Name:VANCOLLINS, PAMELA ELLEN (MSW, LMSW, LPN, QMHP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ELLEN
Last Name:VANCOLLINS
Suffix:
Gender:F
Credentials:MSW, LMSW, LPN, QMHP
Other - Prefix:
Other - First Name:PAMELA VAN COLLINS
Other - Middle Name:BROWN
Other - Last Name:PIERCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LMSW, QMHP, LPN
Mailing Address - Street 1:7338 S DANTE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-2117
Mailing Address - Country:US
Mailing Address - Phone:773-983-6066
Mailing Address - Fax:
Practice Address - Street 1:7338 S DANTE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-2117
Practice Address - Country:US
Practice Address - Phone:773-983-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X
IL43053264164W00000X
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No164W00000XNursing Service ProvidersLicensed Practical Nurse