Basic Information
Provider Information | |||||||||
NPI: | 1912294307 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENDRICKS | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1167 SPRATLIN PARK DR | ||||||||
Address2: |   | ||||||||
City: | GRAY | ||||||||
State: | TN | ||||||||
PostalCode: | 376156205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234673600 | ||||||||
FaxNumber: | 4234673644 | ||||||||
Practice Location | |||||||||
Address1: | 34084 WILDERNESS RD | ||||||||
Address2: |   | ||||||||
City: | JONESVILLE | ||||||||
State: | VA | ||||||||
PostalCode: | 242637899 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2763463590 | ||||||||
FaxNumber: | 2763463612 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2011 | ||||||||
LastUpdateDate: | 07/06/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
No ID Information.