Provider Demographics
NPI:1255952297
Name:PATRICK, JOHN THOMAS (PSYD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:PATRICK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3504 INVERNESS PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-1924
Mailing Address - Country:US
Mailing Address - Phone:850-340-0123
Mailing Address - Fax:
Practice Address - Street 1:2400 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083-5001
Practice Address - Country:US
Practice Address - Phone:334-727-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004339103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty