Basic Information
Provider Information | |||||||||
NPI: | 1407980055 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STARS COMMUNITY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 810 BLUE BILL WAY | ||||||||
Address2: |   | ||||||||
City: | SUISUN CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 945852002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 545 ESTUDILLO AVE | ||||||||
Address2: |   | ||||||||
City: | SAN LEANDRO | ||||||||
State: | CA | ||||||||
PostalCode: | 945774611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5103529200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COOPER | ||||||||
AuthorizedOfficialFirstName: | WILLIEM | ||||||||
AuthorizedOfficialMiddleName: | RICHARDSON | ||||||||
AuthorizedOfficialTitleorPosition: | MENTAL HEALTH SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 5103529200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | II | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X |   |   | Y |   | Agencies | Case Management |   |
No ID Information.