Provider Demographics
NPI:1679096648
Name:ROOSEVELT, PATRICIA A (LPC)
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:A
Last Name:ROOSEVELT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:210 STANHOPE LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-3420
Mailing Address - Country:US
Mailing Address - Phone:618-977-0734
Mailing Address - Fax:618-202-1078
Practice Address - Street 1:1023 EXECUTIVE PARKWAY DR STE 10
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6323
Practice Address - Country:US
Practice Address - Phone:314-469-5522
Practice Address - Fax:314-469-5504
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014034443101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional