Healthcare Provider Details

I. General information

NPI: 1275888943
Provider Name (Legal Business Name): CLEO PATRICK PHD, LCSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 GUNFIGHTER AVE # 366MDG
MOUNTAIN HOME AFB ID
83648-5258
US

IV. Provider business mailing address

5955 ZEAMER AVE # 673MDG
JBER AK
99506-3702
US

V. Phone/Fax

Practice location:
  • Phone: 208-828-7655
  • Fax:
Mailing address:
  • Phone: 907-580-3205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-34797
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number61261680
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: