Basic Information
| Provider Information | |||||||||
| NPI: | 1346300407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOTTENSTEIN | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | LOIS | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOTTENSTEIN | ||||||||
| OtherFirstName: | PAMELA | ||||||||
| OtherMiddleName: | LOIS | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | L.C.S.W. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6547 KRISTINA URSULA CT | ||||||||
| Address2: | |||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220441100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038384455 | ||||||||
| FaxNumber: | 7038385070 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 N SAINT ASAPH ST | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223141912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038384455 | ||||||||
| FaxNumber: | 7038385070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0904005985 | VA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 299161 | 01 | VA | AMERIGROUP | OTHER |