Basic Information
| Provider Information | |||||||||
| NPI: | 1275084899 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STARVISTA GIRLS PROGRAM | ||||||||
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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: | 335 QUARRY RD | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940706217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505916323 | ||||||||
| FaxNumber: | 6505913600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2016 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | DOHERTY | ||||||||
| AuthorizedOfficialFirstName: | LILLIAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | HUMAN RESOURCES DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6505919623 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 94304966 | 01 | CA | MEDI-CAL / NON-PROFIT COUNSELING AGENCY | OTHER |