Provider Demographics
NPI:1043840614
Name:PATRIQUIN, KRAIG MARTIN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KRAIG
Middle Name:MARTIN
Last Name:PATRIQUIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:BERTHOUD
Mailing Address - State:CO
Mailing Address - Zip Code:80513-1018
Mailing Address - Country:US
Mailing Address - Phone:719-649-9320
Mailing Address - Fax:
Practice Address - Street 1:2360 E PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5356
Practice Address - Country:US
Practice Address - Phone:307-778-7550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW12231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty