Provider Demographics
NPI:1962632794
Name:SAN JUAN, NICHOLAS PHILIP
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:PHILIP
Last Name:SAN JUAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 REVERE ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455
Mailing Address - Country:US
Mailing Address - Phone:805-781-3535
Mailing Address - Fax:
Practice Address - Street 1:978 VALECITO CT
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-4740
Practice Address - Country:US
Practice Address - Phone:805-781-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health