Provider Demographics
NPI:1922303999
Name:STARK, DIANNA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DIANNA
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:PO BOX 6384
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92607-6384
Mailing Address - Country:US
Mailing Address - Phone:917-637-0912
Mailing Address - Fax:
Practice Address - Street 1:32242 PASEO ADELANTO
Practice Address - Street 2:SUITE D5
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3610
Practice Address - Country:US
Practice Address - Phone:917-637-0912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR055741-11041C0700X
CALCS654421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical