Provider Demographics
NPI:1467505040
Name:POOR, PATRICK MICHAEL (MFT)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:MICHAEL
Last Name:POOR
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 CENTRAL AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2374
Mailing Address - Country:US
Mailing Address - Phone:951-276-0616
Mailing Address - Fax:951-276-0614
Practice Address - Street 1:4515 CENTRAL AVE STE 102
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2374
Practice Address - Country:US
Practice Address - Phone:951-276-0616
Practice Address - Fax:951-276-0614
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37476106H00000X
UT6278252-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33 BGCPMedicaid