Provider Demographics
NPI:1912050345
Name:HOLDEN, PAMELA SUE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:HOLDEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 GEMINI DR
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-6132
Mailing Address - Country:US
Mailing Address - Phone:505-749-2385
Mailing Address - Fax:
Practice Address - Street 1:501 S ABILENE AVE
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6380
Practice Address - Country:US
Practice Address - Phone:505-359-3707
Practice Address - Fax:505-356-6682
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1174235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00H1139Medicaid