Basic Information
Provider Information | |||||||||
NPI: | 1932710639 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRANSITION-MENTAL HEALTH ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TRANSITIONS MENTAL HEALTH ASSOCIATION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 784 HIGH ST | ||||||||
Address2: |   | ||||||||
City: | SAN LUIS OBISPO | ||||||||
State: | CA | ||||||||
PostalCode: | 934015243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055406587 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1750 BISHOP ST | ||||||||
Address2: |   | ||||||||
City: | SAN LUIS OBISPO | ||||||||
State: | CA | ||||||||
PostalCode: | 934014691 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055406500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2020 | ||||||||
LastUpdateDate: | 01/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALVAREZ | ||||||||
AuthorizedOfficialFirstName: | MEGHAN | ||||||||
AuthorizedOfficialMiddleName: | BOAZ | ||||||||
AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8055406587 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.S. LMFT | ||||||||
NPICertificationDate: | 01/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X |   |   | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
ID Information
ID | Type | State | Issuer | Description | 1790811230 | 01 | CA | NPI | OTHER |