Provider Demographics
NPI:1518026780
Name:PATRICK, LARRY M (LICSW)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:M
Last Name:PATRICK
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 COLLIERS WAY
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5003
Mailing Address - Country:US
Mailing Address - Phone:304-723-5440
Mailing Address - Fax:304-723-0665
Practice Address - Street 1:501 COLLIERS WAY
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5003
Practice Address - Country:US
Practice Address - Phone:304-723-5440
Practice Address - Fax:304-723-0665
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP004542151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVY340644OtherHEALTH PLAN ID NUMBER
WV0005456001Medicaid
WV001718253OtherMSBCBS
WV2070074OtherCIGNA ID NUMBER
WV023533000OtherMAGELLAN MIS NUMBER
PASW05873Medicare PIN