Provider Demographics
NPI:1861686602
Name:CENTRAL COAST COUNSELING CENTER, INC.
Entity Type:Organization
Organization Name:CENTRAL COAST COUNSELING CENTER, INC.
Other - Org Name:CENTRAL COAST COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LMFT & OWNER OF C.C.C.C., INC.
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:805-264-2584
Mailing Address - Street 1:P.O. BOX 2234
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93457-2234
Mailing Address - Country:US
Mailing Address - Phone:805-264-2584
Mailing Address - Fax:805-937-0877
Practice Address - Street 1:2355 LAKE MARIE DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-5709
Practice Address - Country:US
Practice Address - Phone:805-934-5088
Practice Address - Fax:805-937-0877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38335106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ69883ZOtherBLUE SHIELD
CA11688700OtherBLUE CROSS