=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588847818
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK A NORDQUIST LCSW-R
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2007
-----------------------------------------------------
Last Update Date | 12/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 88 BELL HILL RD
-----------------------------------------------------
City | DELHI
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13753-3102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-746-2365
-----------------------------------------------------
Fax | 607-746-8838
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 725
-----------------------------------------------------
City | COOPERSTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13326-0725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-746-2365
-----------------------------------------------------
Fax | 607-746-8838
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 39828
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------