Provider Demographics
NPI:1437415486
Name:STARKS, CLINT (SACIT, LPCIT)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:STARKS
Suffix:
Gender:M
Credentials:SACIT, LPCIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 UNDERWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MONTELLO
Mailing Address - State:WI
Mailing Address - Zip Code:53949-9248
Mailing Address - Country:US
Mailing Address - Phone:608-297-3181
Mailing Address - Fax:608-297-2148
Practice Address - Street 1:480 UNDERWOOD AVE
Practice Address - Street 2:
Practice Address - City:MONTELLO
Practice Address - State:WI
Practice Address - Zip Code:53949-9248
Practice Address - Country:US
Practice Address - Phone:608-297-3181
Practice Address - Fax:608-297-2148
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16564130101YA0400X
WI1577-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)