Healthcare Provider Details

I. General information

NPI: 1831379759
Provider Name (Legal Business Name): ERIC DAVID PENNISTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4129 STATE ST
SANTA BARBARA CA
93110-1848
US

IV. Provider business mailing address

1510 EUCALYPTUS HILL RD APT B2
SANTA BARBARA CA
93103-2874
US

V. Phone/Fax

Practice location:
  • Phone: 805-964-4795
  • Fax:
Mailing address:
  • Phone: 612-702-9194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: