Provider Demographics
NPI:1730634056
Name:ERCOLINO, PATRICK
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:ERCOLINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N DATE ST
Mailing Address - Street 2:
Mailing Address - City:T OR C
Mailing Address - State:NM
Mailing Address - Zip Code:87901-2377
Mailing Address - Country:US
Mailing Address - Phone:575-894-7459
Mailing Address - Fax:
Practice Address - Street 1:405 N DATE ST
Practice Address - Street 2:
Practice Address - City:T OR C
Practice Address - State:NM
Practice Address - Zip Code:87901-2377
Practice Address - Country:US
Practice Address - Phone:575-894-7459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM268273101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM268273OtherSTATE OF NEW MEXICO PED