1417272501 NPI number — TAIRA ST. JOHN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417272501 NPI number — TAIRA ST. JOHN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAIRA ST. JOHN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLEAR LAKE COUNSELING CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417272501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 716
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEPORT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95453-0716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-262-0400
Provider Business Mailing Address Fax Number:
707-262-0340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
149 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
LAKEPORT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95453-4832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-262-0400
Provider Business Practice Location Address Fax Number:
707-262-0340
Provider Enumeration Date:
03/31/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ST. JOHN
Authorized Official First Name:
TAIRA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
707-262-0400

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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