Provider Demographics
NPI:1255464954
Name:VICKERS, PAMELA GAIL (MS, EDS, NCSP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:GAIL
Last Name:VICKERS
Suffix:
Gender:F
Credentials:MS, EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 CAPISTRANO ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-8217
Mailing Address - Country:US
Mailing Address - Phone:540-239-7947
Mailing Address - Fax:
Practice Address - Street 1:2965 COLONNADE DR
Practice Address - Street 2:SUITE 130
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3557
Practice Address - Country:US
Practice Address - Phone:540-989-1703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0803000119103T00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool