=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306996624
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY PATRIC LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 04/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 280 DAVID L GOLDFEIN ST BLDG 23
-----------------------------------------------------
City | HOLLOMAN AFB
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88330-8273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-800-4205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 280 DAVID L GOLDFEIN ST BLDG 23
-----------------------------------------------------
City | HOLLOMAN AFB
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88330-8273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-430-3437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LC5852
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------