Provider Demographics
NPI:1790198414
Name:KACZMARCZYK, PAMELA CHRISTINE (LMP MA 60436997)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:CHRISTINE
Last Name:KACZMARCZYK
Suffix:
Gender:F
Credentials:LMP MA 60436997
Other - Prefix:MRS
Other - First Name:PAMELA
Other - Middle Name:CHRISTINE
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16088 MCLEAN RD
Mailing Address - Street 2:#12
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273
Mailing Address - Country:US
Mailing Address - Phone:360-840-5899
Mailing Address - Fax:
Practice Address - Street 1:100 E MONTGOMERY ST.
Practice Address - Street 2:STE 230
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:360-840-5899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA-60436997225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist