Provider Demographics
NPI:1376929471
Name:PATTISON, EDWARD JR
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:PATTISON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 MONTAGUE ST
Mailing Address - Street 2:8TH FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-3628
Mailing Address - Country:US
Mailing Address - Phone:718-488-0100
Mailing Address - Fax:
Practice Address - Street 1:195 MONTAGUE ST
Practice Address - Street 2:8TH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3628
Practice Address - Country:US
Practice Address - Phone:718-488-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY316079101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid