Provider Demographics
NPI:1467786079
Name:FAGGIANELLI, PATRICK VICTOR JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:VICTOR
Last Name:FAGGIANELLI
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-4015
Mailing Address - Country:US
Mailing Address - Phone:530-848-6571
Mailing Address - Fax:
Practice Address - Street 1:227 E 11TH ST
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-4015
Practice Address - Country:US
Practice Address - Phone:530-848-6571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 19259103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical