Provider Demographics
NPI:1750543401
Name:STARK, NANCY ELLIOTT (LCSW)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:ELLIOTT
Last Name:STARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1335
Mailing Address - Country:US
Mailing Address - Phone:315-788-1530
Mailing Address - Fax:315-755-2538
Practice Address - Street 1:595 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1335
Practice Address - Country:US
Practice Address - Phone:315-788-1530
Practice Address - Fax:315-755-2538
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0785021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical