Provider Demographics
NPI:1063724094
Name:PATE, CARRIE VIRGINIA (LCSW)
Entity type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:VIRGINIA
Last Name:PATE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 BIENVILLE BLVD
Mailing Address - Street 2:SUITE L-1
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3052
Mailing Address - Country:US
Mailing Address - Phone:228-990-8980
Mailing Address - Fax:228-215-1721
Practice Address - Street 1:2112 BIENVILLE BLVD
Practice Address - Street 2:SUITE L-1
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3052
Practice Address - Country:US
Practice Address - Phone:228-990-8980
Practice Address - Fax:228-215-1721
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-07
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC68901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS277763YQRTMedicare PIN