Basic Information
Provider Information | |||||||||
NPI: | 1396087862 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAN LUIS OBISPO COUNTY DRUG AND ALCOHOL SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2180 JOHNSON AVE | ||||||||
Address2: |   | ||||||||
City: | SAN LUIS OBISPO | ||||||||
State: | CA | ||||||||
PostalCode: | 934014513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8057814753 | ||||||||
FaxNumber: | 8057811227 | ||||||||
Practice Location | |||||||||
Address1: | 2545 SPRING ST | ||||||||
Address2: |   | ||||||||
City: | PASO ROBLES | ||||||||
State: | CA | ||||||||
PostalCode: | 93446 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8057814753 | ||||||||
FaxNumber: | 8057811227 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2013 | ||||||||
LastUpdateDate: | 03/22/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GRABER | ||||||||
AuthorizedOfficialFirstName: | STARLENE | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | DIVISION MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8057814753 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD, LMFT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.