Healthcare Provider Details

I. General information

NPI: 1053468207
Provider Name (Legal Business Name): PAMELA QUEZAIRE MSE CSAC ICS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAMELA HAUKENESS

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/08/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PATHWAYS TO A BETTER LIFE, LLC 13111 LAX CHAPEL ROAD
KIEL WI
53042
US

IV. Provider business mailing address

530 STATE ROAD 67 PO BOX 347
KIEL WI
53042
US

V. Phone/Fax

Practice location:
  • Phone: 920-894-1374
  • Fax: 920-894-1373
Mailing address:
  • Phone: 920-286-4462
  • Fax: 920-894-1373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1504.11846
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1504.11846
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: