Basic Information
| Provider Information | |||||||||
| NPI: | 1407230329 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIERRA MENTAL WELLNESS GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2945 MCMILLAN AVENUE, #240 | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934016766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059949915 | ||||||||
| FaxNumber: | 9167839145 | ||||||||
| Practice Location | |||||||||
| Address1: | 2945 MCMILLAN AVENUE, #240 | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934016766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059949915 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2015 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | KERSCHNER | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9167835207 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SIERRA MENTAL WELLNESS GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.