Basic Information
| Provider Information | |||||||||
| NPI: | 1669040838 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STARK | ||||||||
| FirstName: | CECILIA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 N ASH ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826011808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072320159 | ||||||||
| FaxNumber: | 3072320163 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 N ASH ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826011808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072320159 | ||||||||
| FaxNumber: | 3072320163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2021 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 932 | WY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.