Provider Demographics
NPI:1821205600
Name:JOHNSON, PAMELA MAINE (LCSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:MAINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:KAY
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:231 ELMWOOD ST
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77320-3407
Mailing Address - Country:US
Mailing Address - Phone:936-294-9751
Mailing Address - Fax:936-435-2223
Practice Address - Street 1:1204 SAM HOUSTON AVE STE 7
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-4601
Practice Address - Country:US
Practice Address - Phone:936-661-4313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX305691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical