Provider Demographics
NPI:1912550062
Name:STARK, BRANDY (LCSW)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 S GARTHWAITE RD
Mailing Address - Street 2:
Mailing Address - City:GAS CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46933-1155
Mailing Address - Country:US
Mailing Address - Phone:812-447-9580
Mailing Address - Fax:
Practice Address - Street 1:3925 S GARTHWAITE RD
Practice Address - Street 2:
Practice Address - City:GAS CITY
Practice Address - State:IN
Practice Address - Zip Code:46933-1155
Practice Address - Country:US
Practice Address - Phone:812-447-9580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006301A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical