Provider Demographics
NPI:1760548069
Name:WITHERSPOON, PATRICIA BOWIE (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:BOWIE
Last Name:WITHERSPOON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 GRZYB TER
Mailing Address - Street 2:
Mailing Address - City:PARLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08859-3183
Mailing Address - Country:US
Mailing Address - Phone:732-588-5454
Mailing Address - Fax:732-588-5454
Practice Address - Street 1:10819 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420
Practice Address - Country:US
Practice Address - Phone:718-845-2620
Practice Address - Fax:718-845-9380
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00061406104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6013EVMedicaid
NY6013EVMedicaid