Provider Demographics
NPI:1710644828
Name:EZELI, PATRICK
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:EZELI
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 1:7184 CASTLE ROCK WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-8979
Mailing Address - Country:US
Mailing Address - Phone:424-353-1376
Mailing Address - Fax:
Practice Address - Street 1:601 5TH AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4839
Practice Address - Country:US
Practice Address - Phone:909-949-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2025-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4A1B143F93101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool