Provider Demographics
NPI:1225337900
Name:STARK, NATALIE OLIVIA ANN (LISW)
Entity Type:Individual
Prefix:MS
First Name:NATALIE
Middle Name:OLIVIA 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 1:3569 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-5443
Mailing Address - Country:US
Mailing Address - Phone:216-281-0872
Mailing Address - Fax:
Practice Address - Street 1:3569 RIDGE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-5443
Practice Address - Country:US
Practice Address - Phone:216-281-0872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1100372104100000X
171M00000X
OHI.13034991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH08258Medicaid