Provider Demographics
NPI:1669607115
Name:BEVERAGE, PAMELA L (ED D, LPCC)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:L
Last Name:BEVERAGE
Suffix:
Gender:F
Credentials:ED D, LPCC
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 2792
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-2792
Mailing Address - Country:US
Mailing Address - Phone:505-238-3449
Mailing Address - Fax:
Practice Address - Street 1:3500 COMANCHE RD NE
Practice Address - Street 2:SUITE 12
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4546
Practice Address - Country:US
Practice Address - Phone:505-238-3449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0074101101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health