Provider Demographics
NPI:1194931014
Name:GEREDES, MARDI A (MA, RRW)
Entity type:Individual
Prefix:MS
First Name:MARDI
Middle Name:A
Last Name:GEREDES
Suffix:
Gender:F
Credentials:MA, RRW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 MCMILLAN AVE
Mailing Address - Street 2:STE. 136
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6766
Mailing Address - Country:US
Mailing Address - Phone:805-781-1433
Mailing Address - Fax:805-781-1267
Practice Address - Street 1:2945 MCMILLAN AVE
Practice Address - Street 2:STE. 136
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6766
Practice Address - Country:US
Practice Address - Phone:805-781-1433
Practice Address - Fax:805-781-1267
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW0886101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)