Healthcare Provider Details

I. General information

NPI: 1790843167
Provider Name (Legal Business Name): FAMILY SERVICE AGENCY OF THE CENTRAL COAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 WALNUT AVE SUITE 208
SANTA CRUZ CA
95060-3900
US

IV. Provider business mailing address

104 WALNUT AVE SUITE 208
SANTA CRUZ CA
95060-3900
US

V. Phone/Fax

Practice location:
  • Phone: 831-423-9444
  • Fax: 831-423-1532
Mailing address:
  • Phone: 831-423-9444
  • Fax: 831-423-1532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCA

VIII. Authorized Official

Name: DAVID A BIANCHI
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 831-423-9444