Provider Demographics
NPI:1972591246
Name:WILLSON, PAMELA (PHD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WILLSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6605
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85261-6605
Mailing Address - Country:US
Mailing Address - Phone:602-256-9599
Mailing Address - Fax:480-585-6109
Practice Address - Street 1:8035 N 85TH WAY
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4321
Practice Address - Country:US
Practice Address - Phone:602-256-9599
Practice Address - Fax:480-585-6109
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1058103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ73151402OtherAHCCCS
AZ73151402OtherAHCCCS
R14590Medicare UPIN
AZZ21291Medicare PIN