Provider Demographics
NPI:1194827303
Name:STARK, CARL DENNIS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:DENNIS
Last Name:STARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 EMERY HWY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3692
Mailing Address - Country:US
Mailing Address - Phone:478-803-7631
Mailing Address - Fax:478-751-4530
Practice Address - Street 1:HIGHWAY 60 22 WEST
Practice Address - Street 2:BLANDYWAY OFFICE PARK
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061
Practice Address - Country:US
Practice Address - Phone:478-445-1290
Practice Address - Fax:478-445-1296
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA406OtherLCSW