Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 19738 | WI |
NPI | 1003906009 |
---|---|
Provider Name | Patricia M. Kenote-Deperry |
First Address | Bayfield, WI 54814-4818 |
Second Address | Bayfield, WI 54814-4832 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/10/2006 |
Last Update Date | 08/07/2007 |