Provider Demographics
NPI:1376069344
Name:PATTERSON, JULIANNE LUNDELL
Entity Type:Individual
Prefix:
First Name:JULIANNE
Middle Name:LUNDELL
Last Name:PATTERSON
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 1:1033 DAKIN ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-1911
Mailing Address - Country:US
Mailing Address - Phone:517-819-4119
Mailing Address - Fax:
Practice Address - Street 1:3887 OKEMOS RD
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3664
Practice Address - Country:US
Practice Address - Phone:517-992-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI106S00000XMedicaid