Provider Demographics
NPI:1932258225
Name:NANCY LEE STARK DBA INTERCEPT ASSOCIATES
Entity Type:Organization
Organization Name:NANCY LEE STARK DBA INTERCEPT ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:L
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-941-7555
Mailing Address - Street 1:30620 PACIFIC HIGHWAY S
Mailing Address - Street 2:# 107
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003
Mailing Address - Country:US
Mailing Address - Phone:253-941-7555
Mailing Address - Fax:253-941-0652
Practice Address - Street 1:30620 PACIFIC HIGHWAY S
Practice Address - Street 2:# 107
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003
Practice Address - Country:US
Practice Address - Phone:253-941-7555
Practice Address - Fax:253-941-0652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA17004300251B00000X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1995398Medicaid