Basic Information
Provider Information | |||||||||
NPI: | 1336120617 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEROS | ||||||||
FirstName: | PAMELA | ||||||||
MiddleName: | GRACE | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW, QCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 JARRETT WHITE RD | ||||||||
Address2: | TRIPLER ARMY MEDICAL CENTER ATTN: MCHK-QS | ||||||||
City: | TRIPLER AMC | ||||||||
State: | HI | ||||||||
PostalCode: | 968595001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8084332460 | ||||||||
FaxNumber: | 8084331558 | ||||||||
Practice Location | |||||||||
Address1: | U.S. ARMY HEALTH CLINIC - SCHOFIELD BARRACKS | ||||||||
Address2: | BUILDING #681 - 2ND FLOOR | ||||||||
City: | SCHOFIELD BARRACKS | ||||||||
State: | HI | ||||||||
PostalCode: | 96857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8084338565 | ||||||||
FaxNumber: | 8084338551 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3215 | HI | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.