Healthcare Provider Details

I. General information

NPI: 1386629251
Provider Name (Legal Business Name): GARY LEE PATRICK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7767 LIVE OAKS DR
DENVER NC
28037-7410
US

IV. Provider business mailing address

7767 LIVE OAKS DR
DENVER NC
28037-7410
US

V. Phone/Fax

Practice location:
  • Phone: 704-483-9469
  • Fax: 704-483-9469
Mailing address:
  • Phone: 704-483-9469
  • Fax: 704-483-9469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1241
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: