Provider Demographics
NPI:1669040838
Name:STARK, CECILIA MARIE (PCSW)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:MARIE
Last Name:STARK
Suffix:
Gender:F
Credentials:PCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N ASH ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-1808
Mailing Address - Country:US
Mailing Address - Phone:307-232-0159
Mailing Address - Fax:307-232-0163
Practice Address - Street 1:350 N ASH ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1808
Practice Address - Country:US
Practice Address - Phone:307-232-0159
Practice Address - Fax:307-232-0163
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical