Provider Demographics
NPI:1790805885
Name:PRESTBY, PAMELA S (PHD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:S
Last Name:PRESTBY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 N MAYFAIR RD STE 650
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1322
Mailing Address - Country:US
Mailing Address - Phone:414-771-9304
Mailing Address - Fax:414-771-9543
Practice Address - Street 1:2600 N MAYFAIR RD STE 650
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1322
Practice Address - Country:US
Practice Address - Phone:414-771-9304
Practice Address - Fax:414-771-9543
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2250057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39131900Medicaid
WI0003Medicare ID - Type UnspecifiedMEDICARE