Provider Demographics
NPI:1710981477
Name:DATTORE, PATRICK JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JOHN
Last Name:DATTORE
Suffix:
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 1:100 N EDWARD GARY ST
Mailing Address - Street 2:SUITE 103B
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-5726
Mailing Address - Country:US
Mailing Address - Phone:512-392-9472
Mailing Address - Fax:512-392-9472
Practice Address - Street 1:100 N EDWARD GARY ST
Practice Address - Street 2:SUITE 103B
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-5726
Practice Address - Country:US
Practice Address - Phone:512-392-9472
Practice Address - Fax:512-392-9472
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2011-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31285103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1476715-01Medicaid
TX162291OtherCOMPSYCH
TX118398000OtherMAGELLAN
TX0091GZOtherBLUE CROSS/SHIELD
TX1476715-01Medicaid