Basic Information
| Provider Information | |||||||||
| NPI: | 1003140609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATIN | ||||||||
| FirstName: | FRANK | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1651 | ||||||||
| Address2: | |||||||||
| City: | WOODRUFF | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158921673 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 306 HWY 70 E | ||||||||
| Address2: | |||||||||
| City: | SAINT GERMAIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545588800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158921673 | ||||||||
| FaxNumber: | 7153656768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2009 | ||||||||
| LastUpdateDate: | 10/30/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 574-226 | WI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 4595-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 4595-125 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 100015604 | 05 | WI | MEDICAID |