Provider Demographics
NPI:1528365251
Name:PATRICK, MICHELLE RENEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:RENEE
Last Name:PATRICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY PLZ
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4710
Mailing Address - Country:US
Mailing Address - Phone:573-651-2705
Mailing Address - Fax:573-986-4994
Practice Address - Street 1:611 N FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-7244
Practice Address - Country:US
Practice Address - Phone:573-651-2705
Practice Address - Fax:573-986-4994
Is Sole Proprietor?:No
Enumeration Date:2011-02-15
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLP 1649103T00000X
MO2012038439103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist