Basic Information
| Provider Information | |||||||||
| NPI: | 1336343870 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STARVISTA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| 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: | 333 GELLERT BLVD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | DALY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940152621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505919623 | ||||||||
| FaxNumber: | 6505914163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 02/15/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOHERTY | ||||||||
| AuthorizedOfficialFirstName: | LILLIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HUMAN RESOURCES MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6505919623 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
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.