1053468207 NPI number — PAMELA QUEZAIRE MSE CSAC ICS

Table of content: PAMELA QUEZAIRE MSE CSAC ICS (NPI 1053468207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053468207 NPI number — PAMELA QUEZAIRE MSE CSAC ICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUEZAIRE
Provider First Name:
PAMELA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSE CSAC ICS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HAUKENESS
Provider Other First Name:
PAMELA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053468207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
530 STATE ROAD 67
Provider Second Line Business Mailing Address:
PO BOX 347
Provider Business Mailing Address City Name:
KIEL
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-286-4462
Provider Business Mailing Address Fax Number:
920-894-1373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PATHWAYS TO A BETTER LIFE, LLC
Provider Second Line Business Practice Location Address:
13111 LAX CHAPEL ROAD
Provider Business Practice Location Address City Name:
KIEL
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-894-1374
Provider Business Practice Location Address Fax Number:
920-894-1373
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1504.11846 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 1504.11846 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39363000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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