Healthcare Provider Details

I. General information

NPI: 1265564744
Provider Name (Legal Business Name): PAT T STATEN MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N PALM CANYON DR
PALM SPRINGS CA
92262-1868
US

IV. Provider business mailing address

1775 E PALM CANYON DR STE 110
PALM SPRINGS CA
92264-1623
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-2499
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35167
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: