Provider Demographics
NPI:1689230336
Name:PATTERSON, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:PATTERSON
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 1:32151 SW 197TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-6406
Mailing Address - Country:US
Mailing Address - Phone:786-582-0609
Mailing Address - Fax:
Practice Address - Street 1:654 NE 9TH PL
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4934
Practice Address - Country:US
Practice Address - Phone:305-248-3488
Practice Address - Fax:305-248-6558
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-80336106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-19-80336OtherRBT CERTIFICATION