Healthcare Provider Details

I. General information

NPI: 1114108685
Provider Name (Legal Business Name): CHARLES CLINT PATTERSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 GEORGEFF RD
ROLLING HILLS CA
90274-5269
US

IV. Provider business mailing address

22 GEORGEFF RD
ROLLING HILLS CA
90274-5269
US

V. Phone/Fax

Practice location:
  • Phone: 310-944-1420
  • Fax: 310-541-3062
Mailing address:
  • Phone: 310-944-1420
  • Fax: 310-541-3062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY12399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: