Provider Demographics
NPI:1861533630
Name:FORE, PAM L (LICSW)
Entity type:Individual
Prefix:MS
First Name:PAM
Middle Name:L
Last Name:FORE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16610 1ST ST
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:MN
Mailing Address - Zip Code:56455-1134
Mailing Address - Country:US
Mailing Address - Phone:218-546-2716
Mailing Address - Fax:
Practice Address - Street 1:520 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2902
Practice Address - Country:US
Practice Address - Phone:218-829-3235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1022975OtherPREFERRED ONE
MN127665OtherUCARE
MN639B90FOOtherBCBS