Provider Demographics
NPI:1134624331
Name:LAURITA, PATRICK R (TCM)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:R
Last Name:LAURITA
Suffix:
Gender:M
Credentials:TCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3848 LONG BRANCH LN
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-4790
Mailing Address - Country:US
Mailing Address - Phone:321-750-9366
Mailing Address - Fax:
Practice Address - Street 1:3848 LONG BRANCH LN
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-4790
Practice Address - Country:US
Practice Address - Phone:321-750-9366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05Medicaid