Provider Demographics
NPI:1386952364
Name:PATTRIDGE, MARY (LICSW, LADC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PATTRIDGE
Suffix:
Gender:F
Credentials:LICSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-1961
Mailing Address - Country:US
Mailing Address - Phone:575-894-2111
Mailing Address - Fax:
Practice Address - Street 1:800 E 9TH AVE
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-1961
Practice Address - Country:US
Practice Address - Phone:575-894-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300784101YA0400X
MN176481041C0700X
NMC-096991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty