Basic Information
| Provider Information | |||||||||
| NPI: | 1336886217 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOOD SAMARITAN SHELTER | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 400 W PARK AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934586116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053468185 | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 W MORRISON AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934586124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053468185 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2022 | ||||||||
| LastUpdateDate: | 05/12/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | CHELSEA | ||||||||
| AuthorizedOfficialMiddleName: | LAUREL | ||||||||
| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8053473338 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | 05/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.