Provider Demographics
NPI:1285704106
Name:ATWILL, PEGGY JO (MFT)
Entity type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:JO
Last Name:ATWILL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6343
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93412-6343
Mailing Address - Country:US
Mailing Address - Phone:805-234-6435
Mailing Address - Fax:
Practice Address - Street 1:1110 CALIFORNIA BLVD STE E
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2971
Practice Address - Country:US
Practice Address - Phone:805-234-6435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20838101YM0800X
CAMFT20838101YM0800X
101YM0800X
MFC 20838106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health