Healthcare Provider Details

I. General information

NPI: 1730759838
Provider Name (Legal Business Name): PATRICK MICHAEL TENNY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 PRAIRIE AVE
PRAIRIE DU SAC WI
53578-1541
US

IV. Provider business mailing address

PO BOX 301
PORTAGE WI
53901-0301
US

V. Phone/Fax

Practice location:
  • Phone: 608-643-3147
  • Fax: 608-647-3178
Mailing address:
  • Phone: 608-742-5518
  • Fax: 608-742-4087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number785
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number785-228
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: