Provider Demographics
NPI:1477036424
Name:STARK, ELISE A (LPC)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:A
Last Name:STARK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-5404
Mailing Address - Country:US
Mailing Address - Phone:860-685-1254
Mailing Address - Fax:
Practice Address - Street 1:1429 PARK STREET
Practice Address - Street 2:RESET FLOOR ONE
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-0700
Practice Address - Country:US
Practice Address - Phone:860-685-1254
Practice Address - Fax:866-285-7768
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3517101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty