1225243470 NPI number — PAMELA GATES MA LPC, LCDC, INC

Table of content: (NPI 1225243470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225243470 NPI number — PAMELA GATES MA LPC, LCDC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAMELA GATES MA LPC, LCDC, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PAMELA GATES MA. LPC, LCDC, INC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225243470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
616 PETERSON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWAY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78734-4108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-328-2563
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2499 S CAPITAL OF TEXAS HWY
Provider Second Line Business Practice Location Address:
BLDG. B, SUITE 201
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78746-7762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-328-2563
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GATES
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
512-328-2563

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  6991 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0019EX . This is a "BLUE CROSS BLE SHILED" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2163917 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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