Provider Demographics
NPI:1437833324
Name:MCCOURT, PATRICIA DIANE
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:DIANE
Last Name:MCCOURT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:DIANE
Other - Last Name:CLUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:455 SE GOLF PARK BLVD STE 121
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66605-2862
Mailing Address - Country:US
Mailing Address - Phone:785-783-2535
Mailing Address - Fax:
Practice Address - Street 1:455 SE GOLF PARK BLVD STE 121
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66605-2862
Practice Address - Country:US
Practice Address - Phone:785-783-2535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1632101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)