Healthcare Provider Details

I. General information

NPI: 1356959787
Provider Name (Legal Business Name): HEIDI ALYSSA STARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2020
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4024 IVY DR
NAMPA ID
83686-8852
US

IV. Provider business mailing address

4024 IVY DR
NAMPA ID
83686-8852
US

V. Phone/Fax

Practice location:
  • Phone: 208-890-3864
  • Fax:
Mailing address:
  • Phone: 208-890-3864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMSW-38223
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: