MEDICARE: DR. PAMELA DIANE TRICE PSYD, LCPC, LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	227014528	IL
2	101YM0800X	Mental Health Counselor	MH22844	FL
3	101YP2500X	Professional Counselor	180005746	IL

General Provider Information

NPI Number	:	1134181902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAMELA DIANE TRICE PSYD, LCPC, LMT

Provider Business Mailing Address
First Line	:	5878 MIZPAH CT
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33810-1841
Country	:	US
Telephone Number	:	630-207-5537
Fax Number	:	630-221-1606

Provider Business Practice Location Address
First Line	:	5878 MIZPAH CT
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33810-1841
Country	:	US
Telephone Number	:	630-207-5537
Fax Number	:	888-873-1159

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	02/13/2024

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