Provider Demographics
NPI:1548779630
Name:PATTERSON, KIZZY
Entity Type:Individual
Prefix:
First Name:KIZZY
Middle Name:
Last Name:PATTERSON
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 1:6101 HARVEY ST APT 3
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-7549
Mailing Address - Country:US
Mailing Address - Phone:850-541-8991
Mailing Address - Fax:
Practice Address - Street 1:1137 HARRISON AVE STE 13A
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2498
Practice Address - Country:US
Practice Address - Phone:850-778-2233
Practice Address - Fax:850-778-2233
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician