Provider Demographics
NPI:1144656455
Name:WILSON, PAMELA C (LCPC)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:C
Other - Last Name:TOLLEFSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14098 JENNY ANN CT UNIT A
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-5386
Mailing Address - Country:US
Mailing Address - Phone:406-360-8470
Mailing Address - Fax:406-360-8470
Practice Address - Street 1:2809 GREAT NORTHERN LOOP STE 210-5
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1749
Practice Address - Country:US
Practice Address - Phone:406-360-8470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4654101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional