Basic Information
| Provider Information | |||||||||
| NPI: | 1164946133 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAC JC WASHINGTON CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 W CHAPEL ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934584303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059222243 | ||||||||
| FaxNumber: | 8053498165 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 W CHAPEL ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934584303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059222243 | ||||||||
| FaxNumber: | 8053498165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | LAUREL | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL SERVICES DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8052604676 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY ACTION COMMISSION | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PSY.D., LMFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 28718 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1306048905 | 05 | CA | MEDICAID |