Provider Demographics
NPI:1275132847
Name:FAU, PATRICK MOMOH
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:MOMOH
Last Name:FAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 KESSEL CT STE 105
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6227
Mailing Address - Country:US
Mailing Address - Phone:608-280-2700
Mailing Address - Fax:
Practice Address - Street 1:802 E GORHAM ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-1524
Practice Address - Country:US
Practice Address - Phone:608-280-4700
Practice Address - Fax:608-280-4730
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI171M00000X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health