1457894834 NPI number — MS. LAURA CASEY STARBIRD CADC-L CICA01610719

Table of content: MS. LAURA CASEY STARBIRD CADC-L CICA01610719 (NPI 1457894834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457894834 NPI number — MS. LAURA CASEY STARBIRD CADC-L CICA01610719

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STARBIRD
Provider First Name:
LAURA
Provider Middle Name:
CASEY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CADC-L CICA01610719
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1457894834
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4187 ETA ST APT 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92113-4349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-340-6126
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2970 MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92102-3296
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-236-9492
Provider Business Practice Location Address Fax Number:
619-232-0855
Provider Enumeration Date:
12/02/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  CICA01610719 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1831235837 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CICA01610719 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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