Provider Demographics
NPI:1730242256
Name:MARSHALL, PAMELA ANN (LBSW LPCC)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:ANN
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:LBSW LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 ST MICHAELS DR
Mailing Address - Street 2:STE 8A
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-989-3333
Mailing Address - Fax:505-984-3003
Practice Address - Street 1:411 ST MICHAELS DR
Practice Address - Street 2:STE 8A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-989-3333
Practice Address - Fax:505-984-3003
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLPCC1844101YM0800X
NMLBSWB3277104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ5604Medicaid