Provider Demographics
NPI:1053337592
Name:RUSTIN, PAMELA DEMOSTHENES (LCSW, CP CAC II)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:DEMOSTHENES
Last Name:RUSTIN
Suffix:
Gender:F
Credentials:LCSW, CP CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 SAPPHIRE CT
Mailing Address - Street 2:STE 110
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-9079
Mailing Address - Country:US
Mailing Address - Phone:252-830-7561
Mailing Address - Fax:252-413-0932
Practice Address - Street 1:WIESBADEN ARMY SUBSTANCE ABUSE PROGRAM
Practice Address - Street 2:UNIT 29623
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09096
Practice Address - Country:US
Practice Address - Phone:49611-705-1710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0060551041C0700X
SC062231041C0700X
SC64648101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC006055OtherNC BOARD OF SOCIAL WORK
SC06223OtherSC BOARD OF SOCIAL WORK