MEDICARE: SUSAN KINNEY PATRICK LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	16474	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	23659	OTHER	TX	CIGNA
2	5609205	OTHER	TX	AETNA

General Provider Information

NPI Number	:	1447374558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN KINNEY PATRICK LCSW

Provider Business Mailing Address
First Line	:	3412 GEORGETOWN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-2910
Country	:	US
Telephone Number	:	713-521-3537
Fax Number	:	713-662-3646

Provider Business Practice Location Address
First Line	:	3513 AUDUBON PL
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77006-4413
Country	:	US
Telephone Number	:	173-521-3537
Fax Number	:	713-662-3646

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	07/08/2007

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