Basic Information
| Provider Information | |||||||||
| NPI: | 1194931014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEREDES | ||||||||
| FirstName: | MARDI | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, RRW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2945 MCMILLAN AVE | ||||||||
| Address2: | STE. 136 | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934016766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057811433 | ||||||||
| FaxNumber: | 8057811267 | ||||||||
| Practice Location | |||||||||
| Address1: | 2945 MCMILLAN AVE | ||||||||
| Address2: | STE. 136 | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934016766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057811433 | ||||||||
| FaxNumber: | 8057811267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | RW0886 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.