Provider Demographics
NPI:1962773382
Name:ANDERSON, PAMELA K
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:K
Last Name:ANDERSON
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 1:275 REDBUD LN
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4902
Mailing Address - Country:US
Mailing Address - Phone:918-822-4488
Mailing Address - Fax:
Practice Address - Street 1:15481 N JARVIS RD
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-0233
Practice Address - Country:US
Practice Address - Phone:918-456-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst