Healthcare Provider Details

I. General information

NPI: 1770647075
Provider Name (Legal Business Name): REGIINALD EUGENE PATTERSON SR. C.S..A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 SOUTHLAKE BLVD
RICHMOND VA
23236-3955
US

IV. Provider business mailing address

2514 MERLE ST
RICHMOND VA
23231-1936
US

V. Phone/Fax

Practice location:
  • Phone: 804-419-0492
  • Fax: 804-419-0500
Mailing address:
  • Phone: 804-236-8352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710101810
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: