Basic Information
| Provider Information | |||||||||
| NPI: | 1952582850 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAMELA DOUGLAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6722 PATTERSON AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232263400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042824000 | ||||||||
| FaxNumber: | 8042827799 | ||||||||
| Practice Location | |||||||||
| Address1: | 6722 PATTERSON AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232263400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042824000 | ||||||||
| FaxNumber: | 8042827799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 11/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | DOUGLAS | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | KAVANAUGH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8042824000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0015000655 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | C09408 | 01 | VA | MEDICARE GROUP NUMBER | OTHER |