Basic Information
| Provider Information | |||||||||
| NPI: | 1144420191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATINO | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | |||||||||
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| Credential: | CADC-II CA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2087 | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953440087 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 E 13TH ST STE A | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093816850 | ||||||||
| FaxNumber: | 2093853174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2007 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | A021790216 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | AII2701214 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1073635405 | 05 | CA | MEDICAID |