Provider Demographics
NPI:1285108936
Name:WINGARD, PAMELA JO (LMSW)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:JO
Last Name:WINGARD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 W WESTERN AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-1666
Mailing Address - Country:US
Mailing Address - Phone:231-728-3442
Mailing Address - Fax:231-722-0708
Practice Address - Street 1:1050 W WESTERN AVE STE 400
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-1666
Practice Address - Country:US
Practice Address - Phone:231-728-3442
Practice Address - Fax:231-722-0708
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801084946104100000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No104100000XBehavioral Health & Social Service ProvidersSocial Worker