Provider Demographics
NPI:1821206087
Name:CHURCH, PAMELA VERA (MA, LMFT)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:VERA
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 SE 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-2649
Mailing Address - Country:US
Mailing Address - Phone:503-238-1839
Mailing Address - Fax:
Practice Address - Street 1:1732 SE ASH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1526
Practice Address - Country:US
Practice Address - Phone:503-239-8737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0066106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist