Provider Demographics
NPI:1760102792
Name:FATKIN, THOMAS PATRICK
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PATRICK
Last Name:FATKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TOM
Other - Middle Name:PATRICK
Other - Last Name:FATKIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:401 W CIVIC CENTER DR STE 500
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4515
Mailing Address - Country:US
Mailing Address - Phone:714-480-6602
Mailing Address - Fax:714-517-5659
Practice Address - Street 1:401 W CIVIC CENTER DR STE 500
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4515
Practice Address - Country:US
Practice Address - Phone:714-480-6602
Practice Address - Fax:714-517-5659
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)