=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528374774
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFF ROBERT JEFFERY CATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2010
-----------------------------------------------------
Last Update Date | 03/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 S. BENWILEY AVENUE
-----------------------------------------------------
City | SANTA MARIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-332-3439
-----------------------------------------------------
Fax | 805-862-4901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1245
-----------------------------------------------------
City | SANTA MARIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93456-1245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-302-1846
-----------------------------------------------------
Fax | 805-862-4901
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 101687
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------