Provider Demographics
NPI:1114418886
Name:STARK, SUSAN LOUISE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LOUISE
Last Name:STARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 RIO VISTA DR
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89406-5463
Mailing Address - Country:US
Mailing Address - Phone:775-213-3274
Mailing Address - Fax:
Practice Address - Street 1:1001 RIO VISTA DR
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89406-5463
Practice Address - Country:US
Practice Address - Phone:775-213-3274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8485-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical