Provider Demographics
NPI:1780935106
Name:BLACK, PAMELA
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 CAMERON ST STE 11
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-3826
Mailing Address - Country:US
Mailing Address - Phone:702-570-5100
Mailing Address - Fax:
Practice Address - Street 1:4310 CAMERON ST STE 11
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-3826
Practice Address - Country:US
Practice Address - Phone:702-570-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst