Provider Demographics
NPI:1649629700
Name:WIETERS, PAMELA JEAN (LCSW)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
Last Name:WIETERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 BRYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4438
Mailing Address - Country:US
Mailing Address - Phone:208-798-1646
Mailing Address - Fax:
Practice Address - Street 1:428 6TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2355
Practice Address - Country:US
Practice Address - Phone:208-799-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-27529104100000X
IDLCSW-380631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker