Provider Demographics
NPI:1851414429
Name:STARK, JOAN T (MA)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:T
Last Name:STARK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:222 NIZHONI BLVD APT B5
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-7128
Mailing Address - Country:US
Mailing Address - Phone:505-722-7967
Mailing Address - Fax:
Practice Address - Street 1:1000 E AZTEC AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5509
Practice Address - Country:US
Practice Address - Phone:505-721-1825
Practice Address - Fax:505-721-1899
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1776574103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM56306091Medicaid