MEDICARE: THE EADING DISORDER CENTER OF SANTA BARBARA, LLC

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	1041C0700X	Clinical Social Worker	LCS12884	CA

General Provider Information

NPI Number	:	1790058485
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE EADING DISORDER CENTER OF SANTA BARBARA, LLC

Provider Business Mailing Address
First Line	:	27 E VICTORIA ST
Second Line	:	SUITE D
City	:	SANTA BARBARA
State	:	CA
Zip	:	93101-2619
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	27 E VICTORIA ST
Second Line	:	SUITE D
City	:	SANTA BARBARA
State	:	CA
Zip	:	93101-2619
Country	:	US
Telephone Number	:	805-705-3454
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LINDA SUE WELLS
Credential	:	LCSW
Telephone Number	:	805-705-3454

Provider Enumeration Date	:	02/11/2012
Last Update Date	:	02/11/2012

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