MEDICARE: MS. DIANA ALTHEA PATTILLO L.C.S.W.

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	SW3846	FL

General Provider Information

NPI Number	:	1467549733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANA ALTHEA PATTILLO L.C.S.W.

Provider Business Mailing Address
First Line	:	PO BOX 53695
Second Line	:
City	:	FORT BENNING
State	:	GA
Zip	:	31995-3695
Country	:	US
Telephone Number	:	706-507-4762
Fax Number	:

Provider Business Practice Location Address
First Line	:	FT BENNING ASAP
Second Line	:	7950 MARTIN LOOP
City	:	FT BENNING
State	:	GA
Zip	:	31905-0000
Country	:	US
Telephone Number	:	706-545-8371
Fax Number	:

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

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	07/08/2007

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