Provider Demographics
NPI:1023130960
Name:DHIMITRI, PATRICIO (PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:PATRICIO
Middle Name:
Last Name:DHIMITRI
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840-1244
Mailing Address - Country:US
Mailing Address - Phone:978-687-6488
Mailing Address - Fax:978-687-4511
Practice Address - Street 1:599 CANAL ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1244
Practice Address - Country:US
Practice Address - Phone:978-687-6488
Practice Address - Fax:978-687-4511
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2431103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0507962Medicaid
MAWO2659OtherBLUE SHIELD
MA0507962Medicaid