Provider Demographics
NPI:1073055562
Name:PATCH, CAROLYN MARIE
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
Last Name:PATCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30755 AULD RD STE B
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-2581
Mailing Address - Country:US
Mailing Address - Phone:951-696-3112
Mailing Address - Fax:951-696-3445
Practice Address - Street 1:30755 AULD RD STE B
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-2581
Practice Address - Country:US
Practice Address - Phone:951-696-3112
Practice Address - Fax:951-696-3445
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist