Provider Demographics
NPI:1417272501
Name:TAIRA ST. JOHN
Entity Type:Organization
Organization Name:TAIRA ST. JOHN
Other - Org Name:CLEAR LAKE COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ST. JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MFT
Authorized Official - Phone:707-262-0400
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-0716
Mailing Address - Country:US
Mailing Address - Phone:707-262-0400
Mailing Address - Fax:707-262-0340
Practice Address - Street 1:149 N MAIN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-4832
Practice Address - Country:US
Practice Address - Phone:707-262-0400
Practice Address - Fax:707-262-0340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty