Provider Demographics
NPI:1871646174
Name:MATHER, PAMELA (LMFT)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:MATHER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 263
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:VT
Mailing Address - Zip Code:05065-0263
Mailing Address - Country:US
Mailing Address - Phone:802-763-2453
Mailing Address - Fax:
Practice Address - Street 1:4500 E PACIFIC COAST HWY STE 320
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3271
Practice Address - Country:US
Practice Address - Phone:802-763-2453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT100-0000015106H00000X
CA25674106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00069119OtherBLUE CROSS BLUE SHIELD OF
VT1009939Medicaid