Basic Information
| Provider Information | |||||||||
| NPI: | 1639411440 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF SAN LUIS OBISPO | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAN LUIS OBISPO COUNTY DRUG AND ALCOHOL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2180 JOHNSON AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057814753 | ||||||||
| FaxNumber: | 8057811227 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 N THOMPSON AVE | ||||||||
| Address2: | |||||||||
| City: | NIPOMO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934449086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057814753 | ||||||||
| FaxNumber: | 8057811227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2013 | ||||||||
| LastUpdateDate: | 03/31/2014 | ||||||||
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| 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.