Provider Demographics
NPI:1407230329
Name:SIERRA MENTAL WELLNESS GROUP
Entity type:Organization
Organization Name:SIERRA MENTAL WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:VANNEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:916-783-5207
Mailing Address - Street 1:2945 MCMILLAN AVENUE, #240
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6766
Mailing Address - Country:US
Mailing Address - Phone:805-994-9915
Mailing Address - Fax:916-783-9145
Practice Address - Street 1:2975 MCMILLAN AVE STE 164
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6768
Practice Address - Country:US
Practice Address - Phone:805-994-9915
Practice Address - Fax:805-439-4891
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIERRA MENTAL WELLNESS GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-10
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health