Provider Demographics
NPI:1962832329
Name:VANWORMER, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:VANWORMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:MI
Mailing Address - Zip Code:48658-9421
Mailing Address - Country:US
Mailing Address - Phone:989-895-2676
Mailing Address - Fax:
Practice Address - Street 1:1000 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:MI
Practice Address - Zip Code:48658-9421
Practice Address - Country:US
Practice Address - Phone:989-895-2676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010911841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical