Provider Demographics
NPI:1063754653
Name:PATTERSON, GLENROY PATRICK (BCBA)
Entity type:Individual
Prefix:
First Name:GLENROY
Middle Name:PATRICK
Last Name:PATTERSON
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 BIRCHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-1702
Mailing Address - Country:US
Mailing Address - Phone:860-383-4423
Mailing Address - Fax:860-383-4423
Practice Address - Street 1:72 BIRCHWOOD RD
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-1702
Practice Address - Country:US
Practice Address - Phone:860-206-9884
Practice Address - Fax:860-812-2399
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
1-12-11741103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265Medicaid