Basic Information
Provider Information | |||||||||
NPI: | 1770950016 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PATZER | ||||||||
FirstName: | SETH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1387 | ||||||||
Address2: |   | ||||||||
City: | HAYDEN | ||||||||
State: | ID | ||||||||
PostalCode: | 838351387 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2084150299 | ||||||||
FaxNumber: | 2086252070 | ||||||||
Practice Location | |||||||||
Address1: | 622 W COLLEGE AVE | ||||||||
Address2: | SUITE 2 | ||||||||
City: | ST MARIES | ||||||||
State: | ID | ||||||||
PostalCode: | 838611822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082454363 | ||||||||
FaxNumber: | 2082454349 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2015 | ||||||||
LastUpdateDate: | 12/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LMSW34869 | ID | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 38756 | ID | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 38756 | 01 | ID | LICENSE | OTHER | 2094949 | 05 | WA |   | MEDICAID |