Provider Demographics
NPI:1922075209
Name:MEDLAND, PATRICK (LCSW, LMHC, LMFT)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:MEDLAND
Suffix:
Gender:M
Credentials:LCSW, LMHC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 S CLARIZZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5523
Mailing Address - Country:US
Mailing Address - Phone:812-335-5890
Mailing Address - Fax:812-355-5895
Practice Address - Street 1:655 S CLARIZZ BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5523
Practice Address - Country:US
Practice Address - Phone:812-335-5890
Practice Address - Fax:812-355-5895
Is Sole Proprietor?:No
Enumeration Date:2006-03-04
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000428A101YM0800X
IN34002601A1041C0700X, 101Y00000X, 101YA0400X
IN35000705A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000316246OtherANTHEM
000000316246OtherANTHEM