MEDICARE: MRS. PAMELA JO WINGARD LMSW

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	104100000X	Social Worker	6801084946	MI
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1285108936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PAMELA JO WINGARD LMSW

Provider Business Mailing Address
First Line	:	1050 W WESTERN AVE STE 400
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49441-1666
Country	:	US
Telephone Number	:	231-728-3442
Fax Number	:	231-722-0708

Provider Business Practice Location Address
First Line	:	1050 W WESTERN AVE STE 400
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49441-1666
Country	:	US
Telephone Number	:	231-728-3442
Fax Number	:	231-722-0708

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

Provider Enumeration Date	:	01/16/2019
Last Update Date	:	01/16/2019

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