Provider Demographics
NPI:1881982759
Name:LIVELY, PAMELA D (BCBA)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:D
Last Name:LIVELY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3543 BARREL SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2238
Mailing Address - Country:US
Mailing Address - Phone:904-683-6206
Mailing Address - Fax:
Practice Address - Street 1:3543 BARREL SPRINGS DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-2238
Practice Address - Country:US
Practice Address - Phone:904-517-2010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-10-7896103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst