=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285019240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE PATTON PRACTICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2015
-----------------------------------------------------
Last Update Date | 07/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1108 GRECADE ST SUITE 203
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27408-8729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-663-8802
-----------------------------------------------------
Fax | 336-663-8805
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1108 GRECADE ST SUITE 203
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27408-8729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-663-8802
-----------------------------------------------------
Fax | 336-663-8805
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | THERESA ANN KENNEDY PATTON
-----------------------------------------------------
Credential | LCAS, CCS
-----------------------------------------------------
Telephone | 336-663-8802
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1804
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------