Provider Demographics
NPI:1336532407
Name:STARK-MENNEG, EDITH (LMSW, MSC)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:STARK-MENNEG
Suffix:
Gender:F
Credentials:LMSW, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 BRIDGE ST APT 9C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5262
Mailing Address - Country:US
Mailing Address - Phone:617-413-5168
Mailing Address - Fax:
Practice Address - Street 1:19 W 34TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3006
Practice Address - Country:US
Practice Address - Phone:617-413-5168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0901401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical