Basic Information
| Provider Information | |||||||||
| NPI: | 1245400787 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLIAM D. PATENAUDE, PHD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 BANK ST STE 310 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065497325 | ||||||||
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| Practice Location | |||||||||
| Address1: | 125 BANK ST STE 310 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065497325 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2008 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | PATENAUDE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4065497325 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 315 | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 1407905086 | 05 | MT | MEDICAID |