Healthcare Provider Details

I. General information

NPI: 1134181902
Provider Name (Legal Business Name): PAMELA DIANE TRICE PSYD, LCPC, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5878 MIZPAH CT
LAKELAND FL
33810-1841
US

IV. Provider business mailing address

5878 MIZPAH CT
LAKELAND FL
33810-1841
US

V. Phone/Fax

Practice location:
  • Phone: 630-207-5537
  • Fax: 888-873-1159
Mailing address:
  • Phone: 630-207-5537
  • Fax: 630-221-1606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH22844
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180005746
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227014528
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: