Provider Demographics
NPI:1255008470
Name:PATRICK, TELICIA
Entity Type:Individual
Prefix:
First Name:TELICIA
Middle Name:
Last Name:PATRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W LAKE LANSING RD STE C125
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8485
Mailing Address - Country:US
Mailing Address - Phone:517-215-5217
Mailing Address - Fax:517-338-8022
Practice Address - Street 1:411 W LAKE LANSING RD STE C125
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8485
Practice Address - Country:US
Practice Address - Phone:517-215-5217
Practice Address - Fax:517-338-8022
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511101501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical