Provider Demographics
NPI:1275084899
Name:STARVISTA GIRLS PROGRAM
Entity Type:Organization
Organization Name:STARVISTA GIRLS PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HUMAN RESOURCES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-591-9623
Mailing Address - Street 1:610 ELM ST STE 212
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-3070
Mailing Address - Country:US
Mailing Address - Phone:650-591-9623
Mailing Address - Fax:650-591-4163
Practice Address - Street 1:335 QUARRY RD
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-6217
Practice Address - Country:US
Practice Address - Phone:650-591-6323
Practice Address - Fax:650-591-3600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94304966OtherMEDI-CAL / NON-PROFIT COUNSELING AGENCY