Provider Demographics
NPI:1497178073
Name:PATTILLO, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PATTILLO
Suffix:
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 1:2201 RED ELM DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5611
Mailing Address - Country:US
Mailing Address - Phone:281-725-1846
Mailing Address - Fax:
Practice Address - Street 1:2619 N HARVEY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-3017
Practice Address - Country:US
Practice Address - Phone:405-525-3959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-01
Last Update Date:2014-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health