Basic Information
| Provider Information | |||||||||
| NPI: | 1912427048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STARK | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1723 SWIFT CREEK DR | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840417373 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2317 N HILL FIELD RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840414782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015254645 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2017 | ||||||||
| LastUpdateDate: | 06/20/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 91017016004 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.