=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922990472
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAMELA FOLEY SOUTHWORTH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2025
-----------------------------------------------------
Last Update Date | 07/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1840 NEBRASKA ST
-----------------------------------------------------
City | BLAIR
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68008-1577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-650-7036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7517 S 93RD ST
-----------------------------------------------------
City | LA VISTA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68128-4269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-650-7036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 373H00000X
-----------------------------------------------------
Taxonomy Name | Day Training/Habilitation Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------