Basic Information
| Provider Information | |||||||||
| NPI: | 1043727142 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATTERSON | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E 11TH ST | ||||||||
| Address2: | |||||||||
| City: | SAND SPRINGS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740638965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188597626 | ||||||||
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| Practice Location | |||||||||
| Address1: | 23 E ROSS AVE | ||||||||
| Address2: | |||||||||
| City: | SAPULPA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740666423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182164999 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2018 | ||||||||
| LastUpdateDate: | 01/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.