Healthcare Provider Details

I. General information

NPI: 1508107848
Provider Name (Legal Business Name): TIDELANDS COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 MARSH ST STE 105
SAN LUIS OBISPO CA
93401-2967
US

IV. Provider business mailing address

1443 9TH ST
LOS OSOS CA
93402-1701
US

V. Phone/Fax

Practice location:
  • Phone: 805-543-5060
  • Fax: 888-364-3845
Mailing address:
  • Phone: 805-543-5060
  • Fax: 888-364-3845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT #39579
License Number StateCA

VIII. Authorized Official

Name: MR. MAT CHIRMAN
Title or Position: OWNER
Credential: MS, LMFT
Phone: 805-543-5060