=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124596309
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDY ELLEN PATTON CDP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2018
-----------------------------------------------------
Last Update Date | 11/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3420 NE SAND HILL RD
-----------------------------------------------------
City | BELFAIR
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98528-9007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-277-2434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12912 WALLACE RD SE
-----------------------------------------------------
City | OLALLA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98359-9521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-286-8196
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CP60080365
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------