=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861582389
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GENE W COURTER LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1411 MARSH ST. SUITE 108
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-801-8326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 816
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-542-9178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 22980
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------