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General NPI Number Information
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NPI Number | 1508107848
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Entity Type | Organization
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Legal Business Name | TIDELANDS COUNSELING
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Dates
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Enumeration Date | 03/12/2013
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Last Update Date | 03/12/2013
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Provider Practice Location Address
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Address Line | 1411 MARSH ST STE 105
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93401-2967
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Country | US
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Telephone | 805-543-5060
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Fax | 888-364-3845
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Provider Business Mailing Address
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Address Line | 1443 9TH ST
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City | LOS OSOS
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State | CA
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Zip | 93402-1701
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Country | US
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Telephone | 805-543-5060
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Fax | 888-364-3845
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Authorized Official
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Title or Position | OWNER
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Name | MR. MAT CHIRMAN
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Credential | MS, LMFT
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Telephone | 805-543-5060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFT #39579
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License Number State | CA
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