Provider Demographics
NPI:1740376532
Name:BLACKWELL, PAMELA KAY
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:KAY
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAM
Other - Middle Name:KAY
Other - Last Name:BLACKWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:162 GROVE ST STE J
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-2652
Mailing Address - Country:US
Mailing Address - Phone:760-873-6533
Mailing Address - Fax:760-873-3277
Practice Address - Street 1:162 GROVE ST STE J
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2652
Practice Address - Country:US
Practice Address - Phone:760-873-6533
Practice Address - Fax:760-873-3277
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19310106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist