Provider Demographics
NPI:1245400787
Name:WILLIAM D. PATENAUDE, PHD PC
Entity Type:Organization
Organization Name:WILLIAM D. PATENAUDE, PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:PATENAUDE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:406-549-7325
Mailing Address - Street 1:125 BANK ST STE 310
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4413
Mailing Address - Country:US
Mailing Address - Phone:406-549-7325
Mailing Address - Fax:
Practice Address - Street 1:125 BANK ST STE 310
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4413
Practice Address - Country:US
Practice Address - Phone:406-549-7325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT315103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1407905086Medicaid