Basic Information
| Provider Information | |||||||||
| NPI: | 1881805422 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTY OF SAN LUIS OBISPO DRUG AND ALCOHOL SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2180 JOHNSON AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057814558 | ||||||||
| FaxNumber: | 8057811227 | ||||||||
| Practice Location | |||||||||
| Address1: | 1523 LONGBRANCH AVE | ||||||||
| Address2: | |||||||||
| City: | GROVER BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054734759 | ||||||||
| FaxNumber: | 8054737188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 08/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | GRABER | ||||||||
| AuthorizedOfficialFirstName: | STARLENE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIVISON MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8057814759 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD, LMFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 400003DN | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.