Provider Demographics
NPI:1679503148
Name:STARK, ADAM (MA LCMHC LADC)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:STARK
Suffix:
Gender:M
Credentials:MA LCMHC LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39-8 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301
Mailing Address - Country:US
Mailing Address - Phone:802-254-9719
Mailing Address - Fax:802-254-9719
Practice Address - Street 1:122 BIRGE ST 2ND FL.
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301
Practice Address - Country:US
Practice Address - Phone:802-254-9719
Practice Address - Fax:802-254-9719
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000681101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30424122Medicaid
VT1012381Medicaid