MEDICARE: PAMELA ANN WAITKUS LPC LMFT

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	101YP2500X	Professional Counselor	0701002551	VA
2	106H00000X	Marriage & Family Therapist	0717000861	VA

General Provider Information

NPI Number	:	1164508420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA ANN WAITKUS LPC LMFT

Provider Business Mailing Address
First Line	:	3606 BOULEVARD
Second Line	:	SUITE B
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-1341
Country	:	US
Telephone Number	:	804-526-9885
Fax Number	:	804-526-9884

Provider Business Practice Location Address
First Line	:	3606 BOULEVARD
Second Line	:	SUITE B
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-1341
Country	:	US
Telephone Number	:	804-526-9885
Fax Number	:	804-526-9884

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

Provider Enumeration Date	:	10/30/2006
Last Update Date	:	05/02/2008

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