Healthcare Provider Details

I. General information

NPI: 1467549733
Provider Name (Legal Business Name): DIANA ALTHEA PATTILLO L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FT BENNING ASAP 7950 MARTIN LOOP
FT BENNING GA
31905-0000
US

IV. Provider business mailing address

PO BOX 53695
FORT BENNING GA
31995-3695
US

V. Phone/Fax

Practice location:
  • Phone: 706-545-8371
  • Fax:
Mailing address:
  • Phone: 706-507-4762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSW3846
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: