Provider Demographics
NPI:1982889663
Name:BRAITHWAITE, SALLY J (MA)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:J
Last Name:BRAITHWAITE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 OCEAN VIEW AVE APT O
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2658
Mailing Address - Country:US
Mailing Address - Phone:805-865-1943
Mailing Address - Fax:805-865-1954
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:805-865-1954
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 00009296101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health