Provider Demographics
NPI:1952435935
Name:MYTYCH, PAMELA LYNN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:LYNN
Last Name:MYTYCH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N76W16347 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-7426
Mailing Address - Country:US
Mailing Address - Phone:262-251-5781
Mailing Address - Fax:
Practice Address - Street 1:11035 W FOREST HOME AVE
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-2541
Practice Address - Country:US
Practice Address - Phone:414-525-9897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1676-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker