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NPI Code Detail

MEDICARE: TEA MAIN AMFT

MEDICARE: TEA MAIN AMFT
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
1106H00000XMarriage & Family TherapistAMFT138745CA

General Provider Information

NPI Number : 1568157048
Entity Type Code : Individual
Provider Name (Legal Business Name) : TEA MAIN AMFT
Provider Business Mailing Address
First Line : 441 MARSH ST
Second Line :
City : SAN LUIS OBISPO
State : CA
Zip : 93401-6106
Country : US
Telephone Number : 805-457-3545
Fax Number :
Provider Business Practice Location Address
First Line : 441 MARSH ST
Second Line :
City : SAN LUIS OBISPO
State : CA
Zip : 93401-6106
Country : US
Telephone Number : 805-234-8007
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/10/2023
Last Update Date : 06/19/2023

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Directions to “ TEA MAIN AMFT” Practice Location

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