Healthcare Provider Details

I. General information

NPI: 1114175296
Provider Name (Legal Business Name): ROSA V. VAIL LMFT #110739
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 07/21/2022
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E OCEAN AVE
LOMPOC CA
93436-6828
US

IV. Provider business mailing address

401 E. OCEAN AVE
LOMPOC CA
93436
US

V. Phone/Fax

Practice location:
  • Phone: 805-737-6600
  • Fax: 805-737-6601
Mailing address:
  • Phone: 805-737-6600
  • Fax: 805-737-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number100301
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000009153
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerUPIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: