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NPI Code Detail

MEDICARE: CENTRAL COAST COUNSELING CENTER, INC.

MEDICARE: CENTRAL COAST COUNSELING CENTER, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106H00000XMarriage & Family Therapist38335CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1ZZZ69883ZOTHERCABLUE SHIELD
211688700OTHERCABLUE CROSS

General Provider Information

NPI Number : 1861686602
Entity Type Code : Organization
Provider Name (Legal Business Name) : CENTRAL COAST COUNSELING CENTER, INC.
Provider Business Mailing Address
First Line : P.O. BOX 2234
Second Line :
City : SANTA MARIA
State : CA
Zip : 93457-2234
Country : US
Telephone Number : 805-264-2584
Fax Number : 805-937-0877
Provider Business Practice Location Address
First Line : 2355 LAKE MARIE DRIVE
Second Line :
City : SANTA MARIA
State : CA
Zip : 93455-5709
Country : US
Telephone Number : 805-934-5088
Fax Number : 805-937-0877
Authorized Official
Title or Position : LMFT & OWNER OF C.C.C.C., INC.
Name : MRS. MARY JO PEDERSEN
Credential : M.S.
Telephone Number : 805-264-2584
Provider Enumeration Date : 09/05/2007
Last Update Date : 04/19/2023

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