Basic Information
| Provider Information | |||||||||
| NPI: | 1225521123 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOOD SAMARITAN SHELTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LOMPOC RECOVERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 245 INGER DR STE 103-B | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934548669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053468185 | ||||||||
| FaxNumber: | 8004014105 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 W OCEAN AVE | ||||||||
| Address2: | |||||||||
| City: | LOMPOC | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934366630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053473338 | ||||||||
| FaxNumber: | 8004014105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2018 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | CHELSEA | ||||||||
| AuthorizedOfficialMiddleName: | LAUREL | ||||||||
| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8053473338 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | AMFT | ||||||||
| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.