Provider Demographics
NPI:1598115669
Name:STARK, TYLER (LCMHC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:STARK
Suffix:
Gender:M
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11075 S STATE ST STE 16
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-5196
Mailing Address - Country:US
Mailing Address - Phone:801-948-0939
Mailing Address - Fax:
Practice Address - Street 1:11075 S STATE ST STE 16
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-5196
Practice Address - Country:US
Practice Address - Phone:801-948-0939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8598755-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional