Provider Demographics
NPI:1679578561
Name:PATRICK, CAROL L (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:L
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 1:1037 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-2729
Mailing Address - Country:US
Mailing Address - Phone:419-222-5077
Mailing Address - Fax:419-228-5343
Practice Address - Street 1:1037 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2729
Practice Address - Country:US
Practice Address - Phone:419-222-5077
Practice Address - Fax:419-228-5343
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
OH3947103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0691121Medicaid
OH0691121Medicaid
OHCP05381Medicare ID - Type Unspecified