MEDICARE: ELLEN STARBIRD L.C.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	22799	CA

General Provider Information

NPI Number	:	1356539019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN STARBIRD L.C.S.W.

Provider Business Mailing Address
First Line	:	PO BOX 9541
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94709-0541
Country	:	US
Telephone Number	:	510-520-3314
Fax Number	:

Provider Business Practice Location Address
First Line	:	2040 VINE ST
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94709-2034
Country	:	US
Telephone Number	:	510-520-3314
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	10/22/2012

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