Provider Demographics
NPI:1447775028
Name:CAC COLLEGE STREET CENTER
Entity Type:Organization
Organization Name:CAC COLLEGE STREET CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SERVICES ANALYST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LAUREL
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LMFT
Authorized Official - Phone:805-260-4676
Mailing Address - Street 1:648 N G ST
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-5360
Mailing Address - Country:US
Mailing Address - Phone:805-737-7272
Mailing Address - Fax:805-727-7278
Practice Address - Street 1:648 N G ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-5360
Practice Address - Country:US
Practice Address - Phone:805-737-7272
Practice Address - Fax:805-727-7278
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY ACTION COMMSSION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28718101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1457553174Medicaid