Provider Demographics
NPI:1083162226
Name:TYLER M. STARK, LCMHC, CORP.
Entity Type:Organization
Organization Name:TYLER M. STARK, LCMHC, CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:M
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:801-948-0939
Mailing Address - Street 1:11075 S STATE ST STE 16
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-5196
Mailing Address - Country:US
Mailing Address - Phone:801-948-0939
Mailing Address - Fax:
Practice Address - Street 1:11075 S STATE ST STE 16
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-5196
Practice Address - Country:US
Practice Address - Phone:801-948-0939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8598755-6004251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health