Provider Demographics
NPI:1679710362
Name:PATTON STATE HOSPITAL
Entity type:Organization
Organization Name:PATTON STATE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:TAMANAHA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:909-425-7363
Mailing Address - Street 1:3102 E HIGHLAND AVE
Mailing Address - Street 2:PROGRAM 4, UNIT 35
Mailing Address - City:PATTON
Mailing Address - State:CA
Mailing Address - Zip Code:92369-7813
Mailing Address - Country:US
Mailing Address - Phone:909-425-7363
Mailing Address - Fax:909-425-6208
Practice Address - Street 1:3102 E HIGHLAND AVE
Practice Address - Street 2:PROGRAM 4, UNIT 35
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369-7813
Practice Address - Country:US
Practice Address - Phone:909-425-7363
Practice Address - Fax:909-425-6208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21662283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital