Healthcare Provider Details

I. General information

NPI: 1477176717
Provider Name (Legal Business Name): PAMELA CHRISTINE VICKERS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2020
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 S MARGINAL RD
CLEVELAND OH
44103-1072
US

IV. Provider business mailing address

5500 S MARGINAL RD
CLEVELAND OH
44103-1072
US

V. Phone/Fax

Practice location:
  • Phone: 601-260-7984
  • Fax:
Mailing address:
  • Phone: 216-221-7588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2103406
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: