Healthcare Provider Details

I. General information

NPI: 1740841402
Provider Name (Legal Business Name): RIDE THE WAVE RECOVERY: PROFESSIONAL CLINICAL COUNSELOR PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 WALNUT AVE STE 200
SANTA CRUZ CA
95060-3929
US

IV. Provider business mailing address

104 WALNUT AVE STE 200
SANTA CRUZ CA
95060-3929
US

V. Phone/Fax

Practice location:
  • Phone: 831-275-5481
  • Fax:
Mailing address:
  • Phone: 831-275-5481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KATHERINE M ZWICK
Title or Position: EXECUTIVE DIRECTOR
Credential: LPCC
Phone: 831-275-5481