Provider Demographics
NPI:1013938604
Name:LINNELL, PAMELA W (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:W
Last Name:LINNELL
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:PO BOX 1178
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1178
Mailing Address - Country:US
Mailing Address - Phone:505-622-4519
Mailing Address - Fax:505-623-3232
Practice Address - Street 1:1210 N MAIN ST STE 304
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5016
Practice Address - Country:US
Practice Address - Phone:505-622-4519
Practice Address - Fax:505-623-3232
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM759103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM76675Medicaid
NMP10040Medicare UPIN
NM76675Medicaid