Provider Demographics
NPI:1780167098
Name:PATE, LANDON (BT)
Entity type:Individual
Prefix:
First Name:LANDON
Middle Name:
Last Name:PATE
Suffix:
Gender:M
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4002
Mailing Address - Country:US
Mailing Address - Phone:318-795-3388
Mailing Address - Fax:
Practice Address - Street 1:2522 E 70TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4002
Practice Address - Country:US
Practice Address - Phone:318-795-3388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARBT-18-64074106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
LARBT-18-64074OtherBACB