=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790996684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAMELA WILSON VANDENAKER M.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 05/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 S 1300 W
-----------------------------------------------------
City | PLEASANT GROVE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84062-3580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-785-9400
-----------------------------------------------------
Fax | 801-785-9499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 S 1300 W
-----------------------------------------------------
City | PLEASANT GROVE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84062-3580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-785-9400
-----------------------------------------------------
Fax | 801-785-9499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 973368026004
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------