MEDICARE: CONSCIOUS AWAKENING LICENSED MARRIAGE FAMILY THERAPIST 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
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1992549547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONSCIOUS AWAKENING LICENSED MARRIAGE FAMILY THERAPIST INC.

Provider Business Mailing Address
First Line	:	PO BOX 2043
Second Line	:
City	:	PISMO BEACH
State	:	CA
Zip	:	93448-2043
Country	:	US
Telephone Number	:	805-550-3621
Fax Number	:

Provider Business Practice Location Address
First Line	:	11549 LOS OSOS VALLEY RD STE 202
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93405-6481
Country	:	US
Telephone Number	:	805-550-3621
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST/OWNER
Name	:	JENNIFER ANN WOODWARD
Credential	:	LMFT
Telephone Number	:	805-550-3621

Provider Enumeration Date	:	06/19/2024
Last Update Date	:	06/19/2024

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