Provider Demographics
NPI:1629544101
Name:RACHEL, PATRICE N
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:N
Last Name:RACHEL
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 1:2526 RODMAN ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-5848
Mailing Address - Country:US
Mailing Address - Phone:786-712-8302
Mailing Address - Fax:
Practice Address - Street 1:2526 RODMAN ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-5848
Practice Address - Country:US
Practice Address - Phone:786-712-8302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-42889103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23731300Medicaid