Provider Demographics
NPI:1720279730
Name:PATRICIO, VIENNA MONIQUE (CDC)
Entity Type:Individual
Prefix:
First Name:VIENNA
Middle Name:MONIQUE
Last Name:PATRICIO
Suffix:
Gender:F
Credentials:CDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2332 WARMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-4554
Mailing Address - Country:US
Mailing Address - Phone:310-831-8764
Mailing Address - Fax:
Practice Address - Street 1:2332 WARMOUTH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-4554
Practice Address - Country:US
Practice Address - Phone:310-831-8764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)