Provider Demographics
NPI:1245415009
Name:PATE, MILDRED LOUISE (DT)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:LOUISE
Last Name:PATE
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 4 BOX 222
Mailing Address - Street 2:
Mailing Address - City:MC LEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859-9461
Mailing Address - Country:US
Mailing Address - Phone:618-773-4541
Mailing Address - Fax:
Practice Address - Street 1:RR 4 BOX 222
Practice Address - Street 2:
Practice Address - City:MC LEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859-9461
Practice Address - Country:US
Practice Address - Phone:618-773-4541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-29
Last Update Date:2007-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILMP14130298P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist