Healthcare Provider Details

I. General information

NPI: 1720191521
Provider Name (Legal Business Name): TISA STARR MA/MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 HIGH ST
AUBURN CA
95603-5015
US

IV. Provider business mailing address

1212 HIGH ST
AUBURN CA
95603-5015
US

V. Phone/Fax

Practice location:
  • Phone: 530-888-6595
  • Fax: 530-823-8387
Mailing address:
  • Phone: 530-888-6595
  • Fax: 530-823-8387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39967
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: