Provider Demographics
NPI:1801169420
Name:STARK, ELLEN (LSW)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4955 S DURANGO DR STE 207
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-0156
Mailing Address - Country:US
Mailing Address - Phone:702-650-6508
Mailing Address - Fax:702-893-9655
Practice Address - Street 1:4955 S DURANGO DR STE 207
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-0156
Practice Address - Country:US
Practice Address - Phone:702-650-6508
Practice Address - Fax:702-893-9655
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL04303600103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation