Provider Demographics
NPI:1356594915
Name:PATRICK, THERESA ANN
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ANN
Last Name:PATRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SHAMROCK DR
Mailing Address - Street 2:
Mailing Address - City:PUTNAM VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10579-2908
Mailing Address - Country:US
Mailing Address - Phone:845-528-7835
Mailing Address - Fax:
Practice Address - Street 1:29 SHAMROCK DR
Practice Address - Street 2:
Practice Address - City:PUTNAM VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10579-2908
Practice Address - Country:US
Practice Address - Phone:845-528-7835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004117-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist