Provider Demographics
NPI:1346769775
Name:STARK, ANGELA RENEE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:RENEE
Last Name:STARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 TEXAS ST STE 203
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3723
Mailing Address - Country:US
Mailing Address - Phone:619-692-0727
Mailing Address - Fax:
Practice Address - Street 1:3978 SORRENTO VALLEY BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121
Practice Address - Country:US
Practice Address - Phone:858-428-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician