MEDICARE: CENTRAL COAST EATING DISORDER PROGRAM SERVICES AND WORKSHOP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1205090719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL COAST EATING DISORDER PROGRAM SERVICES AND WORKSHOP

Provider Business Mailing Address
First Line	:	PO BOX 835
Second Line	:
City	:	SANTA YNEZ
State	:	CA
Zip	:	93460-0835
Country	:	US
Telephone Number	:	805-688-5057
Fax Number	:

Provider Business Practice Location Address
First Line	:	1851 SHELL BEACH RD
Second Line	:
City	:	SHELL BEACH
State	:	CA
Zip	:	93449-1860
Country	:	US
Telephone Number	:	805-688-5057
Fax Number	:

Authorized Official
Title or Position	:	CEO, DIRECTOR
Name	:	MR. TERRELL WHITE
Credential	:	MFT
Telephone Number	:	805-688-5656

Provider Enumeration Date	:	07/14/2008
Last Update Date	:	07/14/2008

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