Provider Demographics
NPI:1164647269
Name:PATSIS, PENELOPE M (PHD)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:M
Last Name:PATSIS
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 1:14 SOUNDCREST LN
Mailing Address - Street 2:
Mailing Address - City:LLOYD HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11743-9790
Mailing Address - Country:US
Mailing Address - Phone:631-225-2465
Mailing Address - Fax:631-549-1796
Practice Address - Street 1:152 N WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4046
Practice Address - Country:US
Practice Address - Phone:631-225-2465
Practice Address - Fax:631-549-1797
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010883103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV73341Medicare ID - Type UnspecifiedPSYCHOLOGIST