Healthcare Provider Details

I. General information

NPI: 1457718686
Provider Name (Legal Business Name): PAMELA FENNO BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S BURDICK ST
KALAMAZOO MI
49007-5221
US

IV. Provider business mailing address

610 S BURDICK ST
KALAMAZOO MI
49007-5221
US

V. Phone/Fax

Practice location:
  • Phone: 269-381-3700
  • Fax: 269-381-3810
Mailing address:
  • Phone: 269-381-3700
  • Fax: 269-381-3810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802060204
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: