1861686602 NPI number — CENTRAL COAST COUNSELING CENTER, INC.

Table of content: (NPI 1861686602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861686602 NPI number — CENTRAL COAST COUNSELING CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL COAST COUNSELING CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861686602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2234
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA MARIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93457-2234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-264-2584
Provider Business Mailing Address Fax Number:
805-937-0877

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2355 LAKE MARIE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA MARIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93455-5709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-934-5088
Provider Business Practice Location Address Fax Number:
805-937-0877
Provider Enumeration Date:
09/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PEDERSEN
Authorized Official First Name:
MARY
Authorized Official Middle Name:
JO
Authorized Official Title or Position:
LMFT & OWNER OF C.C.C.C., INC.
Authorized Official Telephone Number:
805-264-2584

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  38335 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ69883Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 11688700 . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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