Provider Demographics
NPI:1841066511
Name:MCTILLER, PAMELA F (EXECUTIVE DIRECTOR)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:F
Last Name:MCTILLER
Suffix:
Gender:F
Credentials:EXECUTIVE DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10309 WAYSIDE DR NE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35810-6300
Mailing Address - Country:US
Mailing Address - Phone:256-348-4908
Mailing Address - Fax:
Practice Address - Street 1:3928 NEPTUNE DR NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35810-1374
Practice Address - Country:US
Practice Address - Phone:256-348-4908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2401541320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities