=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881805422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTY OF SAN LUIS OBISPO DRUG AND ALCOHOL SERVICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2007
-----------------------------------------------------
Last Update Date | 08/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1523 LONGBRANCH AVE
-----------------------------------------------------
City | GROVER BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-473-4759
-----------------------------------------------------
Fax | 805-473-7188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2180 JOHNSON AVE
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93401-4558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-781-4558
-----------------------------------------------------
Fax | 805-781-1227
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIVISON MANAGER
-----------------------------------------------------
Name | DR. STARLENE M GRABER
-----------------------------------------------------
Credential | PHD, LMFT
-----------------------------------------------------
Telephone | 805-781-4759
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 400003DN
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------