MEDICARE: PAMELA BEATRICE LICCARDI LCPC/LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	32924	MT
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	32949	MT
3	101YM0800X	Mental Health Counselor	32924	MT
4	101YP2500X	Professional Counselor	32924	MT

General Provider Information

NPI Number	:	1063989275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA BEATRICE LICCARDI LCPC/LAC

Provider Business Mailing Address
First Line	:	1701 BLUESTONE DR UNIT B
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-7556
Country	:	US
Telephone Number	:	406-407-8911
Fax Number	:

Provider Business Practice Location Address
First Line	:	1203 US HIGHWAY 2 W
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-6071
Country	:	US
Telephone Number	:	406-314-6565
Fax Number	:	406-314-6566

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2018
Last Update Date	:	10/08/2024

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