Provider Demographics
NPI:1447542766
Name:DUSTMAN, PAMELA BELLE (PCC-S LICDC)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:BELLE
Last Name:DUSTMAN
Suffix:
Gender:F
Credentials:PCC-S LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 N LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-3113
Mailing Address - Country:US
Mailing Address - Phone:440-428-0055
Mailing Address - Fax:440-428-0084
Practice Address - Street 1:65 N LAKE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-3113
Practice Address - Country:US
Practice Address - Phone:440-428-0055
Practice Address - Fax:440-428-0084
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH981326101YA0400X
OHE2125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)