Basic Information
| Provider Information | |||||||||
| NPI: | 1982889663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAITHWAITE | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 241 OCEAN VIEW AVE APT O | ||||||||
| Address2: | |||||||||
| City: | PISMO BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934492658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058651943 | ||||||||
| FaxNumber: | 8058651954 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 N SAN ANTONIO RD | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931101316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056815220 | ||||||||
| FaxNumber: | 8058651954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2007 | ||||||||
| LastUpdateDate: | 12/31/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LH 00009296 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.