Basic Information
| Provider Information | |||||||||
| NPI: | 1538341375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATRICK | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS CCCSLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PATRICK | ||||||||
| OtherFirstName: | KEVIN | ||||||||
| OtherMiddleName: | JOSEPH | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS CCCSLP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065149 | ||||||||
| FaxNumber: | 9712065209 | ||||||||
| Practice Location | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065149 | ||||||||
| FaxNumber: | 9712065209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2007 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP658 | NV | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.