Provider Demographics
NPI:1912418922
Name:PATTON, MARY JUDITH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JUDITH
Last Name:PATTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 VAN NESS AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4200
Mailing Address - Country:US
Mailing Address - Phone:831-818-4030
Mailing Address - Fax:
Practice Address - Street 1:157 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4200
Practice Address - Country:US
Practice Address - Phone:831-818-4030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102295101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health