Provider Demographics
NPI:1396819793
Name:DESJARDIN, PATRICIA A (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:DESJARDIN
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N BRIDGE STREET
Mailing Address - Street 2:ROOM 122
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-1876
Mailing Address - Country:US
Mailing Address - Phone:715-726-7788
Mailing Address - Fax:715-726-4560
Practice Address - Street 1:711 N BRIDGE STREET
Practice Address - Street 2:ROOM 122
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-1876
Practice Address - Country:US
Practice Address - Phone:715-726-7788
Practice Address - Fax:715-726-4560
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11731231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39637400Medicaid
WI54173OtherSECURITY HEALTH