Provider Demographics
NPI:1154592558
Name:FORMO-PATTON, CYNTHIA L (OT)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:L
Last Name:FORMO-PATTON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:L
Other - Last Name:FORMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 E BROADWAY AVE
Mailing Address - Street 2:PO BOX 5510
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58506-5510
Mailing Address - Country:US
Mailing Address - Phone:701-530-8833
Mailing Address - Fax:
Practice Address - Street 1:900 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4520
Practice Address - Country:US
Practice Address - Phone:701-530-8833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND503225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND503OtherLICENSE