Basic Information
| Provider Information | |||||||||
| NPI: | 1033373873 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRANSITIONS SANTA MARIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GATEHOUSE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15408 | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934065408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055415144 | ||||||||
| FaxNumber: | 8055419480 | ||||||||
| Practice Location | |||||||||
| Address1: | 1112 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934546608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059280139 | ||||||||
| FaxNumber: | 8059281410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2008 | ||||||||
| LastUpdateDate: | 07/15/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOLSTER-WHITE | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8055415144 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRANSITIONS MENTAL HEALTH ASSOCIATION | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.