Provider Demographics
NPI:1124596309
Name:PATTON, JUDY ELLEN (CDP)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:ELLEN
Last Name:PATTON
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12912 WALLACE RD SE
Mailing Address - Street 2:
Mailing Address - City:OLALLA
Mailing Address - State:WA
Mailing Address - Zip Code:98359-9521
Mailing Address - Country:US
Mailing Address - Phone:360-286-8196
Mailing Address - Fax:
Practice Address - Street 1:3420 NE SAND HILL RD
Practice Address - Street 2:
Practice Address - City:BELFAIR
Practice Address - State:WA
Practice Address - Zip Code:98528-9007
Practice Address - Country:US
Practice Address - Phone:360-277-2434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60080365101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)