Provider Demographics
NPI:1790164812
Name:STARK, JULIE L (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:L
Last Name:STARK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 NESCONSET HWY STE 108
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-2512
Mailing Address - Country:US
Mailing Address - Phone:646-696-0011
Mailing Address - Fax:
Practice Address - Street 1:111 NESCONSET HWY
Practice Address - Street 2:SUITE 108
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11788-2524
Practice Address - Country:US
Practice Address - Phone:646-696-0011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-21
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093478-1104100000X
NY086538-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker