Basic Information
| Provider Information | |||||||||
| NPI: | 1194929638 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STARVISTA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | YOUTH AND FAMILY ENRICHMENT SERVICES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 ELM ST STE 212 | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940703070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505919623 | ||||||||
| FaxNumber: | 6505914163 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 S CLAREMONT ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944021447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505919623 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 08/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | DOHERTY | ||||||||
| AuthorizedOfficialFirstName: | LILLIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HUMAN RESOURCES MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6505919623 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.