Provider Demographics
NPI:1962247924
Name:PATOCKA, PHILLIP DEAN II (RADT)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:DEAN
Last Name:PATOCKA
Suffix:II
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12781 JOSEPHINE ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-4622
Mailing Address - Country:US
Mailing Address - Phone:657-251-0503
Mailing Address - Fax:
Practice Address - Street 1:12781 JOSEPHINE ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-4622
Practice Address - Country:US
Practice Address - Phone:657-251-0503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1560300524106S00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician