Provider Demographics
NPI:1669416269
Name:DEITZ, PAMELA (LCSW/MFT)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:DEITZ
Suffix:
Gender:F
Credentials:LCSW/MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30101 TOWN CENTER DR
Mailing Address - Street 2:STE. 109
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-5006
Mailing Address - Country:US
Mailing Address - Phone:949-488-2699
Mailing Address - Fax:949-218-6461
Practice Address - Street 1:30101 TOWN CENTER DR
Practice Address - Street 2:STE. 109
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-5006
Practice Address - Country:US
Practice Address - Phone:949-488-2699
Practice Address - Fax:949-218-6461
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW73171041C0700X
CAM12160106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11331408OtherCAQH
CA11331408OtherCAQH