Basic Information
| Provider Information | |||||||||
| NPI: | 1114262516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VEREECKEN | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | T | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4908 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832054908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082361600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 353 N 4TH AVE | ||||||||
| Address2: | STE 110 | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832016390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082337832 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2012 | ||||||||
| LastUpdateDate: | 12/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.