Provider Demographics
NPI:1922760776
Name:STARK, KYLIE A
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:A
Last Name:STARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 I94 BUSINESS LOOP E
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-6434
Mailing Address - Country:US
Mailing Address - Phone:701-227-7506
Mailing Address - Fax:
Practice Address - Street 1:1463 I94 BUSINESS LOOP E
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-6434
Practice Address - Country:US
Practice Address - Phone:701-227-7506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 174400000X
ND1211-7-1-22A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist