Provider Demographics
NPI:1003053760
Name:STARK, PATRICIA ANN (LISW)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:ANN
Last Name:STARK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SAINT MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7615
Mailing Address - Country:US
Mailing Address - Phone:505-473-6362
Mailing Address - Fax:505-473-6467
Practice Address - Street 1:1600 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7615
Practice Address - Country:US
Practice Address - Phone:505-473-6362
Practice Address - Fax:505-473-6467
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-062631041C0700X
CALCS176041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical