Healthcare Provider Details

I. General information

NPI: 1982192084
Provider Name (Legal Business Name): SIERRA MENTAL WELLNESS GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4558
US

IV. Provider business mailing address

333 SUNRISE AVE STE 701
ROSEVILLE CA
95661-3483
US

V. Phone/Fax

Practice location:
  • Phone: 805-788-2507
  • Fax: 805-788-2506
Mailing address:
  • Phone: 916-783-5207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: NICOLE VANNEMAN
Title or Position: INTERIM EXECUTIVE DIRECTOR
Credential: LMFT
Phone: 916-783-5207