Provider Demographics
NPI:1841467636
Name:LISTLE, PAMELA (MSCCSLP)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:
Last Name:LISTLE
Suffix:
Gender:F
Credentials:MSCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 WEST ADAMS ST.
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615
Mailing Address - Country:US
Mailing Address - Phone:715-284-5361
Mailing Address - Fax:715-284-7166
Practice Address - Street 1:711 WEST ADAMS ST.
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615
Practice Address - Country:US
Practice Address - Phone:715-284-5361
Practice Address - Fax:715-284-7166
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI721-154235Z00000X
WI235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist