Provider Demographics
NPI:1861642100
Name:STARK, NINA A (LCSW,BCD)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:A
Last Name:STARK
Suffix:
Gender:F
Credentials:LCSW,BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8950 VILLA LA JOLLA DR STE C113
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1703
Mailing Address - Country:US
Mailing Address - Phone:760-633-2437
Mailing Address - Fax:858-459-4651
Practice Address - Street 1:8950 VILLA LA JOLLA DR STE C113
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1703
Practice Address - Country:US
Practice Address - Phone:760-633-2437
Practice Address - Fax:858-459-4651
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 4510101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health