Provider Demographics
NPI:1235368135
Name:FORTUNE, PATRICE (PHD)
Entity Type:Individual
Prefix:DR
First Name:PATRICE
Middle Name:
Last Name:FORTUNE
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 1:63 BOVET ROAD #221
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-3104
Mailing Address - Country:US
Mailing Address - Phone:650-999-6650
Mailing Address - Fax:
Practice Address - Street 1:63 BOVET ROAD #221
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-3104
Practice Address - Country:US
Practice Address - Phone:650-619-9942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB 36721103TC0700X
CA80309106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical