Provider Demographics
NPI:1750679122
Name:HUCKABY, PAMELA DIANE (LCSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DIANE
Last Name:HUCKABY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:DIANE
Other - Last Name:LEAVENWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:663 W 950 S
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3021
Mailing Address - Country:US
Mailing Address - Phone:435-734-9449
Mailing Address - Fax:435-723-4851
Practice Address - Street 1:663 W 950 S
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3021
Practice Address - Country:US
Practice Address - Phone:435-734-9449
Practice Address - Fax:435-723-4851
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10387650-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical