Healthcare Provider Details

I. General information

NPI: 1114007259
Provider Name (Legal Business Name): PAMELA MAE PEDERSEN LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 S LINCOLN AVE SUITE 1
YORK NE
68467-4216
US

IV. Provider business mailing address

71 KUESTER LAKE
GRAND ISLAND NE
68801
US

V. Phone/Fax

Practice location:
  • Phone: 402-362-6128
  • Fax: 402-362-7012
Mailing address:
  • Phone: 308-382-5356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number326
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: