MEDICARE: MS. PATRICIA MARY SLACK ATR-BC, LCAT, CASAC

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	221700000X	Art Therapist	ATR-BC 92-321	NY

General Provider Information

NPI Number	:	1477694479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PATRICIA MARY SLACK ATR-BC, LCAT, CASAC

Provider Business Mailing Address
First Line	:	116 PRIMROSE LN
Second Line	:
City	:	NORTH SYRACUSE
State	:	NY
Zip	:	13212-4230
Country	:	US
Telephone Number	:	315-457-2107
Fax Number	:

Provider Business Practice Location Address
First Line	:	116 PRIMROSE LN
Second Line	:
City	:	NORTH SYRACUSE
State	:	NY
Zip	:	13212-4230
Country	:	US
Telephone Number	:	315-457-2107
Fax Number	:

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

Provider Enumeration Date	:	02/11/2007
Last Update Date	:	07/08/2007

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