Provider Demographics
NPI:1679606677
Name:PATRIARCA, GWEN (SLP)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:PATRIARCA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19000
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88102-9000
Mailing Address - Country:US
Mailing Address - Phone:575-769-4490
Mailing Address - Fax:575-769-4533
Practice Address - Street 1:1600 SUTTER PLACE
Practice Address - Street 2:STUDENT SUPPORT CENTER
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88012-9000
Practice Address - Country:US
Practice Address - Phone:575-769-4490
Practice Address - Fax:575-769-4533
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM655235Z00000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK 3216Medicaid