Provider Demographics
NPI:1912307711
Name:STARK, ERRICKA (CAPSW, BCBA)
Entity Type:Individual
Prefix:
First Name:ERRICKA
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:CAPSW, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-3923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6601 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-3923
Practice Address - Country:US
Practice Address - Phone:262-880-5864
Practice Address - Fax:262-995-7333
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI214-140103K00000X
WI128554-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI214-140OtherDEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES
1-17-28076OtherBEHAVIOR ANALYST CERTIFICATION BOARD