Healthcare Provider Details

I. General information

NPI: 1912374802
Provider Name (Legal Business Name): PAM KOAGEL CASAC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W COURT ST
ROME NY
13440-5707
US

IV. Provider business mailing address

201 W COURT ST
ROME NY
13440-5707
US

V. Phone/Fax

Practice location:
  • Phone: 315-281-9363
  • Fax:
Mailing address:
  • Phone: 315-281-9363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001233
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: