MEDICARE: PATTRA FARTHING DODD 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1942546551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATTRA FARTHING DODD LCSW

Provider Business Mailing Address
First Line	:	1901 S 25TH ST
Second Line	:	SUITE 103
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4711
Country	:	US
Telephone Number	:	772-595-5150
Fax Number	:	772-595-6560

Provider Business Practice Location Address
First Line	:	1901 S 25TH ST
Second Line	:	SUITE 103
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4711
Country	:	US
Telephone Number	:	772-595-5150
Fax Number	:	772-595-6560

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

Provider Enumeration Date	:	12/31/2012
Last Update Date	:	01/25/2014

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