Healthcare Provider Details

I. General information

NPI: 1457975351
Provider Name (Legal Business Name): CAPTIVE HEARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

882 W GRAND AVE
GROVER BEACH CA
93433-2134
US

IV. Provider business mailing address

882 W GRAND AVE
GROVER BEACH CA
93433-2134
US

V. Phone/Fax

Practice location:
  • Phone: 805-481-4500
  • Fax:
Mailing address:
  • Phone: 805-602-8751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name: ELISSA ROSE GOODENOUGH
Title or Position: BOARD MEMBER/ EMPLOYEE
Credential:
Phone: 805-602-8751