Provider Demographics
NPI:1528425121
Name:PINE, PATRICIA DARLENE
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:DARLENE
Last Name:PINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N MAIN ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:WOODSTOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22664-1851
Mailing Address - Country:US
Mailing Address - Phone:540-247-3275
Mailing Address - Fax:540-459-2039
Practice Address - Street 1:1205 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664-1024
Practice Address - Country:US
Practice Address - Phone:540-247-3275
Practice Address - Fax:540-301-5239
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-27
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0102732002Medicaid