Healthcare Provider Details

I. General information

NPI: 1487121323
Provider Name (Legal Business Name): AMBER SHEALENE LAROE-WINTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E HICKORY AVE
LOMPOC CA
93436-7274
US

IV. Provider business mailing address

PO BOX 5067
SANTA MARIA CA
93456-5067
US

V. Phone/Fax

Practice location:
  • Phone: 805-350-3201
  • Fax:
Mailing address:
  • Phone: 805-350-3201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number838
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number78240
License Number StateCA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: