Healthcare Provider Details

I. General information

NPI: 1447126610
Provider Name (Legal Business Name): PAMELA PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 S HEMLOCK ST STE 1
IRON MOUNTAIN MI
49801-3800
US

IV. Provider business mailing address

100 MALTON RD
NEGAUNEE MI
49866-2001
US

V. Phone/Fax

Practice location:
  • Phone: 906-774-2561
  • Fax:
Mailing address:
  • Phone: 906-451-4889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: