Provider Demographics
NPI:1528633922
Name:PHILIP, PAMELA MOSES
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:MOSES
Last Name:PHILIP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18121 GOLDFINCH WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-2023
Mailing Address - Country:US
Mailing Address - Phone:952-715-7833
Mailing Address - Fax:
Practice Address - Street 1:18121 GOLDFINCH WAY
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-2023
Practice Address - Country:US
Practice Address - Phone:952-715-7833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty