Provider Demographics
NPI:1780103119
Name:BINGHAM, PATILLE (LMSW)
Entity type:Individual
Prefix:
First Name:PATILLE
Middle Name:
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25704
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-0704
Mailing Address - Country:US
Mailing Address - Phone:505-559-2200
Mailing Address - Fax:505-848-9468
Practice Address - Street 1:12200 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-5804
Practice Address - Country:US
Practice Address - Phone:505-559-2200
Practice Address - Fax:505-848-9468
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-102801041S0200X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty