Healthcare Provider Details

I. General information

NPI: 1598177206
Provider Name (Legal Business Name): SLO COUNTY BEHAVORIAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

IV. Provider business mailing address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

V. Phone/Fax

Practice location:
  • Phone: 805-781-4712
  • Fax: 805-781-4145
Mailing address:
  • Phone: 805-781-4712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number02016035
License Number StateCA

VIII. Authorized Official

Name: MS. KATHLEEN LAURIE WELLES
Title or Position: MENTAL HEALTHWORKER
Credential: MHW
Phone: 805-781-4712