Basic Information
| Provider Information | |||||||||
| NPI: | 1003801028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | KAVANAUGH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MSN,APRN,BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6722 PATTERSON AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232263419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042824000 | ||||||||
| FaxNumber: | 8042827799 | ||||||||
| Practice Location | |||||||||
| Address1: | 6722 PATTERSON AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232263419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042824000 | ||||||||
| FaxNumber: | 8042827799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0015000655 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.