Provider Demographics
NPI:1679935126
Name:PATRICK, DAVID LELAND (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:LELAND
Last Name:PATRICK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JACKSON CREEK RD
Mailing Address - Street 2:#2263
Mailing Address - City:CLANCY
Mailing Address - State:MT
Mailing Address - Zip Code:59634-9714
Mailing Address - Country:US
Mailing Address - Phone:406-461-1656
Mailing Address - Fax:406-791-9629
Practice Address - Street 1:611 NW YATES LOOP
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-7101
Practice Address - Country:US
Practice Address - Phone:406-461-1656
Practice Address - Fax:406-791-9629
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-165181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM011007880Medicare PIN