Healthcare Provider Details

I. General information

NPI: 1104176148
Provider Name (Legal Business Name): CORTNY M STARK MA, LPCC, LADAC, CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 JACKIE RD SE STE 900
RIO RANCHO NM
87124
US

IV. Provider business mailing address

2605 INCA RD NE
RIO RANCHO NM
87144-7558
US

V. Phone/Fax

Practice location:
  • Phone: 505-289-1042
  • Fax:
Mailing address:
  • Phone: 505-452-7635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAD0171001
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number00165351
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0198781
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: