Basic Information
Provider Information | |||||||||
NPI: | 1306983887 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STARVISTA GIRLS PROGRAM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 610 ELM STREET, SUITE 212 | ||||||||
Address2: |   | ||||||||
City: | SAN CARLOS | ||||||||
State: | CA | ||||||||
PostalCode: | 94070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6505919623 | ||||||||
FaxNumber: | 6505914163 | ||||||||
Practice Location | |||||||||
Address1: | 400 PAUL SCANNELL DRIVE | ||||||||
Address2: |   | ||||||||
City: | SAN MATEO | ||||||||
State: | CA | ||||||||
PostalCode: | 94402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6505919623 | ||||||||
FaxNumber: | 6505914163 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2007 | ||||||||
LastUpdateDate: | 08/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DOHERTY | ||||||||
AuthorizedOfficialFirstName: | LILLIAN | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | HUMAN RESOURCES MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6505919623 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.