Provider Demographics
NPI:1063989275
Name:LICCARDI, PAMELA BEATRICE (LCPC/LAC)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:BEATRICE
Last Name:LICCARDI
Suffix:
Gender:F
Credentials:LCPC/LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 BLUESTONE DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-7556
Mailing Address - Country:US
Mailing Address - Phone:406-407-8911
Mailing Address - Fax:
Practice Address - Street 1:1203 US HIGHWAY 2 W
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-6071
Practice Address - Country:US
Practice Address - Phone:406-314-6565
Practice Address - Fax:406-314-6566
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT32924101Y00000X, 101YM0800X, 101YP2500X
MT32949101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health