Healthcare Provider Details

I. General information

NPI: 1992107007
Provider Name (Legal Business Name): CENTER FOR THERAPEUTIC ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 14TH ST SUITE B
PASO ROBLES CA
93446-2285
US

IV. Provider business mailing address

625 14TH ST SUITE B
PASO ROBLES CA
93446-2285
US

V. Phone/Fax

Practice location:
  • Phone: 805-876-5413
  • Fax: 805-876-5412
Mailing address:
  • Phone: 805-876-5413
  • Fax: 805-876-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY26358
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC49152
License Number StateCA

VIII. Authorized Official

Name: PATRICIA M GLICKMAN
Title or Position: PARTNER
Credential: MFT
Phone: 805-610-8729