Provider Demographics
NPI:1730759838
Name:TENNY, PATRICK MICHAEL
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:MICHAEL
Last Name:TENNY
Suffix:
Gender:M
Credentials:
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 301
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0301
Mailing Address - Country:US
Mailing Address - Phone:608-742-5518
Mailing Address - Fax:608-742-4087
Practice Address - Street 1:50 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-1541
Practice Address - Country:US
Practice Address - Phone:608-643-3147
Practice Address - Fax:608-647-3178
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI785106H00000X
WI785-228101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1730759838Medicaid