Provider Demographics
NPI:1720015274
Name:PATRICK, JOHN WALTER (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WALTER
Last Name:PATRICK
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 1:5911 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-6445
Mailing Address - Country:US
Mailing Address - Phone:386-761-3101
Mailing Address - Fax:
Practice Address - Street 1:4643 S CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 306
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-6000
Practice Address - Country:US
Practice Address - Phone:386-761-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3313103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical