Provider Demographics
NPI:1164704482
Name:RAIBORN, STARLA RENE
Entity Type:Individual
Prefix:
First Name:STARLA
Middle Name:RENE
Last Name:RAIBORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9229 STEEL FIELD RD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32413-9453
Mailing Address - Country:US
Mailing Address - Phone:850-381-9789
Mailing Address - Fax:
Practice Address - Street 1:2708 NE 14TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-3565
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist