Provider Demographics
NPI:1255497285
Name:STARK, MADELINE A (LMSW)
Entity Type:Individual
Prefix:MS
First Name:MADELINE
Middle Name:A
Last Name:STARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 70 BOX 371
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:NM
Mailing Address - Zip Code:87552
Mailing Address - Country:US
Mailing Address - Phone:505-757-6851
Mailing Address - Fax:505-989-4357
Practice Address - Street 1:1225 ST FRANCIS DR SUITE F
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-989-7777
Practice Address - Fax:505-989-4357
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM3807104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM101190Medicaid