Provider Demographics
NPI:1730550922
Name:LACKRAM, PAMELA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:LACKRAM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3543 26TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2541
Mailing Address - Country:US
Mailing Address - Phone:509-844-3536
Mailing Address - Fax:
Practice Address - Street 1:15265 MINNETONKA BLVD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-1510
Practice Address - Country:US
Practice Address - Phone:952-223-2506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9335235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist