Healthcare Provider Details

I. General information

NPI: 1770612293
Provider Name (Legal Business Name): SHERISE NATALIA STARK MSW, PPS, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8770 HARBISON CANYON RD
ALPINE CA
91901-2615
US

IV. Provider business mailing address

8770 HARBISON CANYON RD
ALPINE CA
91901-2615
US

V. Phone/Fax

Practice location:
  • Phone: 619-445-2977
  • Fax:
Mailing address:
  • Phone: 619-445-2977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number28429
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15618
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: