Basic Information
| Provider Information | |||||||||
| NPI: | 1982192084 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIERRA MENTAL WELLNESS GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 SUNRISE AVE STE 701 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167835207 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2180 B JOHNSON AVENUE | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057882505 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2018 | ||||||||
| LastUpdateDate: | 04/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | TOSTE | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | TECHNICAL SERVICES SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9167835207 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SIERRA MENTAL WELLNESS GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.