Healthcare Provider Details

I. General information

NPI: 1356482533
Provider Name (Legal Business Name): PAMELA WALKER VREDEVELT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SE 223RD AVE SUITE 204
GRESHAM OR
97030-7454
US

IV. Provider business mailing address

1558 SW WALTERS LOOP
GRESHAM OR
97080-5322
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-7733
  • Fax: 503-661-7890
Mailing address:
  • Phone: 503-661-7733
  • Fax: 503-661-7890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC CO280
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: