Provider Demographics
NPI:1912102310
Name:STARK, CASSI (LIMHP)
Entity Type:Individual
Prefix:
First Name:CASSI
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 894
Mailing Address - Street 2:
Mailing Address - City:PONCA
Mailing Address - State:NE
Mailing Address - Zip Code:68770-0894
Mailing Address - Country:US
Mailing Address - Phone:308-631-9456
Mailing Address - Fax:308-532-0389
Practice Address - Street 1:1000 W 29TH ST STE 230
Practice Address - Street 2:
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-3852
Practice Address - Country:US
Practice Address - Phone:402-913-0552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1812101YM0800X
NE8324101YM0800X
IA082666101YM0800X
NE854101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025953600Medicaid