Provider Demographics
NPI:1831176940
Name:PATTERSON, KATHLEEN S (PHD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:S
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-0215
Mailing Address - Country:US
Mailing Address - Phone:601-466-8141
Mailing Address - Fax:
Practice Address - Street 1:1119 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-3111
Practice Address - Country:US
Practice Address - Phone:601-466-8141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS33-514103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000188309OtherANTHEM BLUE CROSS
IN343411OtherMHN
IN200226850Medicaid
IN326003OtherVALUE OPTIONS
IN000000188309OtherANTHEM BLUE CROSS