Provider Demographics
NPI:1053468207
Name:QUEZAIRE, PAMELA (MSE CSAC ICS)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:QUEZAIRE
Suffix:
Gender:F
Credentials:MSE CSAC ICS
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:HAUKENESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:530 STATE ROAD 67
Mailing Address - Street 2:PO BOX 347
Mailing Address - City:KIEL
Mailing Address - State:WI
Mailing Address - Zip Code:53042
Mailing Address - Country:US
Mailing Address - Phone:920-286-4462
Mailing Address - Fax:920-894-1373
Practice Address - Street 1:PATHWAYS TO A BETTER LIFE, LLC
Practice Address - Street 2:13111 LAX CHAPEL ROAD
Practice Address - City:KIEL
Practice Address - State:WI
Practice Address - Zip Code:53042
Practice Address - Country:US
Practice Address - Phone:920-894-1374
Practice Address - Fax:920-894-1373
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1504.11846101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39363000Medicaid