Provider Demographics
NPI:1588787972
Name:PATTY, JOHN M (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:PATTY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6220 LA SALLE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-2804
Mailing Address - Country:US
Mailing Address - Phone:925-937-8637
Mailing Address - Fax:
Practice Address - Street 1:6220 LA SALLE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-2804
Practice Address - Country:US
Practice Address - Phone:925-937-8637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 10001103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0PL100012Medicare ID - Type Unspecified