Provider Demographics
NPI:1891431151
Name:STARK, NICOLE DENISE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:DENISE
Last Name:STARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:D
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7600 WOOD HOLLOW DR APT 206
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-2242
Mailing Address - Country:US
Mailing Address - Phone:714-726-3767
Mailing Address - Fax:
Practice Address - Street 1:7600 WOOD HOLLOW DR APT 206
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-2242
Practice Address - Country:US
Practice Address - Phone:714-726-3767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX645701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical