Healthcare Provider Details

I. General information

NPI: 1699065524
Provider Name (Legal Business Name): HEIDI GABRIELA STARK-BANK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEIDI GABRIELA STARK PH.D.

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 08/17/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W 190TH ST STE 280
GARDENA CA
90248-4305
US

IV. Provider business mailing address

PO BOX 60193
LAS VEGAS NV
89160-0193
US

V. Phone/Fax

Practice location:
  • Phone: 877-515-8113
  • Fax:
Mailing address:
  • Phone: 858-977-1878
  • Fax: 702-365-0602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPY0641
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY0641
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY24810
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY 6041
License Number StateNV
# 5
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY0641
License Number StateNV
# 6
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSY24810
License Number StateNV
# 7
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPY0641
License Number StateNV
# 8
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY24810
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: