Provider Demographics
NPI:1992853022
Name:REAVES, PAMELA LOY (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:LOY
Last Name:REAVES
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 1:315 LAS COLINDAS RD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2407
Mailing Address - Country:US
Mailing Address - Phone:415-450-5616
Mailing Address - Fax:
Practice Address - Street 1:2925 SHATTUCK AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1808
Practice Address - Country:US
Practice Address - Phone:415-450-5616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14187103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL141870Medicare UPIN
CAOPL141870Medicare ID - Type UnspecifiedMEDICARE