Provider Demographics
NPI:1356959787
Name:STARK, HEIDI ALYSSA
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:ALYSSA
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 1:4024 IVY DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-8852
Mailing Address - Country:US
Mailing Address - Phone:208-890-3864
Mailing Address - Fax:
Practice Address - Street 1:4024 IVY DR
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-8852
Practice Address - Country:US
Practice Address - Phone:208-890-3864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106H00000X
IDLMSW-38223101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist