=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285704106
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PEGGY JO ATWILL MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 12/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1110 CALIFORNIA BLVD STE E
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93401-2971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-234-6435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6343
-----------------------------------------------------
City | LOS OSOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93412-6343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-234-6435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 20838
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MFT20838
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC 20838
-----------------------------------------------------
License Number State |
-----------------------------------------------------