Provider Demographics
NPI:1962473009
Name:SUBSTANCE ABUSE REHABILITATION PROGRAM
Entity Type:Organization
Organization Name:SUBSTANCE ABUSE REHABILITATION PROGRAM
Other - Org Name:SARP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LIP/CLINIC HEAD
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILLIAMSON COE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MFT
Authorized Official - Phone:619-556-7635
Mailing Address - Street 1:34800 BOB WILSON DR
Mailing Address - Street 2:NMCSD, ATTN: MEDICAL STAFF SERVICES
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1098
Mailing Address - Country:US
Mailing Address - Phone:619-556-7635
Mailing Address - Fax:619-556-9842
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:NMCSD, ATTN: MEDICAL STAFF SERVICES
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-556-7635
Practice Address - Fax:619-556-9842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 25227106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty