Provider Demographics
NPI:1306491774
Name:PEARLS OF WISDOM PSYCHIATRIC
Entity type:Organization
Organization Name:PEARLS OF WISDOM PSYCHIATRIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RN MSN
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:PARDON
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:440-444-1395
Mailing Address - Street 1:5295 OBERLIN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3454
Mailing Address - Country:US
Mailing Address - Phone:440-444-1395
Mailing Address - Fax:
Practice Address - Street 1:5295 OBERLIN AVE STE A
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3454
Practice Address - Country:US
Practice Address - Phone:440-444-1395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-02
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0133139Medicaid