Provider Demographics
NPI:1023213832
Name:FEE-FOR-SERVICE PSYCHIATRIST
Entity Type:Organization
Organization Name:FEE-FOR-SERVICE PSYCHIATRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QA COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NED
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-681-5101
Mailing Address - Street 1:300 N SAN ANTONIO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93110-1316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 N SAN ANTONIO RD
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93110-1316
Practice Address - Country:US
Practice Address - Phone:805-681-5220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service