Provider Demographics
NPI:1841226768
Name:FORMICA, PAMELA ANN I (LCMHC, LADC)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:ANN
Last Name:FORMICA
Suffix:I
Gender:F
Credentials:LCMHC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 MAPLE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4562
Mailing Address - Country:US
Mailing Address - Phone:802-863-4800
Mailing Address - Fax:802-862-9339
Practice Address - Street 1:231 MAPLE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4562
Practice Address - Country:US
Practice Address - Phone:802-863-4800
Practice Address - Fax:802-862-9339
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000348101YA0400X
VT0680000601101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)