Provider Demographics
NPI:1063496115
Name:FANTONI-SALVADOR, PATRICIA M (PHD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:FANTONI-SALVADOR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10002 AURORA AVE N STE 36
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-9348
Mailing Address - Country:US
Mailing Address - Phone:206-257-1061
Mailing Address - Fax:206-257-1061
Practice Address - Street 1:7601 NW 13TH CT
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-4705
Practice Address - Country:US
Practice Address - Phone:206-257-1061
Practice Address - Fax:206-257-1061
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5902103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL762864100Medicaid
FLE6645BMedicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST
FLP00119877Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST
FLE6645AMedicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST