Provider Demographics
NPI:1376235457
Name:PATTISHALL, ELISABETH MYRIAM TAINA
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:MYRIAM TAINA
Last Name:PATTISHALL
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 1:140 LOS BANOS AVE
Mailing Address - Street 2:
Mailing Address - City:MOSS BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:94038-9744
Mailing Address - Country:US
Mailing Address - Phone:415-312-2279
Mailing Address - Fax:
Practice Address - Street 1:1900 S NORFOLK ST STE 205
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1184
Practice Address - Country:US
Practice Address - Phone:650-242-0179
Practice Address - Fax:650-242-8202
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician