Basic Information
| Provider Information | |||||||||
| NPI: | 1528126422 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEHAVIORAL HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAN LUIS OBISPO COUNTY MENATAL HEALTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3860 COLIMA RD | ||||||||
| Address2: | |||||||||
| City: | ATASCADERO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934222520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054669423 | ||||||||
| FaxNumber: | 8054616061 | ||||||||
| Practice Location | |||||||||
| Address1: | 5575 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | ATASCADERO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054616060 | ||||||||
| FaxNumber: | 8054616061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STREET | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH THERAPIST IV | ||||||||
| AuthorizedOfficialTelephone: | 8054616060 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | I | ||||||||
| AuthorizedOfficialCredential: | PSYCH. TECHNICIAN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305S00000X | PT 22453 | CA | N | Managed Care Organizations | Point of Service | 305S00000X | PT22453 | CA | Y | Managed Care Organizations | Point of Service |
No ID Information.