Healthcare Provider Details

I. General information

NPI: 1306998786
Provider Name (Legal Business Name): COASTAL CENTER FOR ANXIETY TREATMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1194 PACIFIC ST STE 101 SUITE B-2
SAN LUIS OBISPO CA
93401-3338
US

IV. Provider business mailing address

1194 PACIFIC ST STE 101 SUITE B-2
SAN LUIS OBISPO CA
93401-3338
US

V. Phone/Fax

Practice location:
  • Phone: 805-473-3388
  • Fax: 805-548-0815
Mailing address:
  • Phone: 805-473-3388
  • Fax: 805-548-0815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY20248
License Number StateCA

VIII. Authorized Official

Name: DR. ERIC D GOODMAN
Title or Position: DIRECTOR
Credential: PHD
Phone: 805-473-3388