Provider Demographics
NPI:1871718312
Name:VINCENT, PAMELA J (B S)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:J
Last Name:VINCENT
Suffix:
Gender:F
Credentials:B S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 N MCQUEEN RD
Mailing Address - Street 2:#1163
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-3946
Mailing Address - Country:US
Mailing Address - Phone:480-963-4382
Mailing Address - Fax:
Practice Address - Street 1:1460 N PINAL AVE
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-3337
Practice Address - Country:US
Practice Address - Phone:480-963-4382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0345235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ583600Medicaid