Provider Demographics
NPI:1780712943
Name:STARK, DIANE JEAN (MSSW LCSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:JEAN
Last Name:STARK
Suffix:
Gender:F
Credentials:MSSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5034 THOROUGHBRED LN STE D
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4231
Mailing Address - Country:US
Mailing Address - Phone:615-507-2082
Mailing Address - Fax:615-507-2085
Practice Address - Street 1:5034 THOROUGHBRED LN STE D
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-4231
Practice Address - Country:US
Practice Address - Phone:615-507-2082
Practice Address - Fax:615-507-2085
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN746101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0122302OtherBLUE CROSS BLUE SHIELD
TN1105848OtherCIGNA BEHAVIORAL HEALTH