Provider Demographics
NPI:1275602807
Name:PATRICK, PETER D (PHD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:D
Last Name:PATRICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 EMMET STREET, S
Mailing Address - Street 2:P.O. BOX 400270
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22904-4270
Mailing Address - Country:US
Mailing Address - Phone:434-924-7034
Mailing Address - Fax:434-924-4621
Practice Address - Street 1:417 EMMET STREET, SOUTH
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22904-4270
Practice Address - Country:US
Practice Address - Phone:434-924-7034
Practice Address - Fax:434-924-4621
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000756103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ44899AMedicare PIN