Basic Information
Provider Information
NPI: 1003140609
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PATIN
FirstName: FRANK
MiddleName: CHARLES
NamePrefix: MR.
NameSuffix:  
Credential: LPC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X4595-125WIN Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
101YM0800X574-226WIN Behavioral Health & Social Service ProvidersCounselorMental Health
101YP2500X4595-125WIY Behavioral Health & Social Service ProvidersCounselorProfessional

ID Information
IDTypeStateIssuerDescription
10001560405WI MEDICAID


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