Healthcare Provider Details

I. General information

NPI: 1053337592
Provider Name (Legal Business Name): PAMELA DEMOSTHENES RUSTIN LCSW, CP CAC II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WIESBADEN ARMY SUBSTANCE ABUSE PROGRAM UNIT 29623
APO AE
09096
US

IV. Provider business mailing address

4300 SAPPHIRE CT STE 110
GREENVILLE NC
27834-9079
US

V. Phone/Fax

Practice location:
  • Phone: 496117051710
  • Fax:
Mailing address:
  • Phone: 252-830-7561
  • Fax: 252-413-0932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC006055
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06223
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number64648
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: