Provider Demographics
NPI:1043383698
Name:STARK, CATHERINE ANN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:ANN
Last Name:STARK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1444
Mailing Address - Street 2:
Mailing Address - City:WALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07719
Mailing Address - Country:US
Mailing Address - Phone:609-242-4090
Mailing Address - Fax:
Practice Address - Street 1:540 LACEY ROAD
Practice Address - Street 2:SUITE 1B
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731
Practice Address - Country:US
Practice Address - Phone:609-242-4090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC046160001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
003299Medicare ID - Type Unspecified