Provider Demographics
NPI:1114007259
Name:PEDERSEN, PAMELA MAE (LADC)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:MAE
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 KUESTER LAKE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801
Mailing Address - Country:US
Mailing Address - Phone:308-382-5356
Mailing Address - Fax:
Practice Address - Street 1:722 S LINCOLN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:YORK
Practice Address - State:NE
Practice Address - Zip Code:68467-4216
Practice Address - Country:US
Practice Address - Phone:402-362-6128
Practice Address - Fax:402-362-7012
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE326101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47052851509Medicaid
NE47052851517Medicaid
NE47052851582Medicaid
85276OtherBCBS