Provider Demographics
NPI:1598443020
Name:PATRICK, SHANE (MA, DMIN, THM, MS)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:PATRICK
Suffix:
Gender:M
Credentials:MA, DMIN, THM, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20402 63RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-8630
Mailing Address - Country:US
Mailing Address - Phone:210-995-1099
Mailing Address - Fax:
Practice Address - Street 1:13128 TOTEM LAKE BLVD NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2953
Practice Address - Country:US
Practice Address - Phone:425-202-7748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health