Provider Demographics
NPI:1174022966
Name:IDE, PATRICK SAL (MA, LPCA)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:SAL
Last Name:IDE
Suffix:
Gender:M
Credentials:MA, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12884 S FRONTRUNNER BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5488
Mailing Address - Country:US
Mailing Address - Phone:336-423-7697
Mailing Address - Fax:
Practice Address - Street 1:1922 S MARTIN LUTHER KING JR DR STE 255
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-1361
Practice Address - Country:US
Practice Address - Phone:336-464-3136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1912446253Medicaid