Basic Information
| Provider Information | |||||||||
| NPI: | 1780103119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BINGHAM | ||||||||
| FirstName: | PATILLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25704 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871250704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055592200 | ||||||||
| FaxNumber: | 5058489468 | ||||||||
| Practice Location | |||||||||
| Address1: | 12200 LOMAS BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871125804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055592200 | ||||||||
| FaxNumber: | 5058489468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2017 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | X-10280 | NM | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | School | 101YM0800X | X-10280 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.