Provider Demographics
NPI:1841322518
Name:WIGGINS, PAMELA GWEN (LCAS LICENSED CLINIC)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:GWEN
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:LCAS LICENSED CLINIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:968 NORTHSHORE DR
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-4051
Mailing Address - Country:US
Mailing Address - Phone:336-672-1955
Mailing Address - Fax:336-629-7501
Practice Address - Street 1:727 SOUTH FAYETTEVILLE ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203
Practice Address - Country:US
Practice Address - Phone:336-672-7500
Practice Address - Fax:336-629-7501
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC145101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14384OtherBCBS
NC6111891Medicaid