Provider Demographics
NPI:1174887681
Name:STARK, KEITH A
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:STARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10701 S EASTERN AVE APT 2618
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4901
Mailing Address - Country:US
Mailing Address - Phone:702-538-0230
Mailing Address - Fax:
Practice Address - Street 1:3450 E RUSSELL RD
Practice Address - Street 2:210
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-2201
Practice Address - Country:US
Practice Address - Phone:702-629-4354
Practice Address - Fax:702-644-0475
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst