Healthcare Provider Details

I. General information

NPI: 1174887681
Provider Name (Legal Business Name): KEITH A STARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 E RUSSELL RD 210
LAS VEGAS NV
89120-2201
US

IV. Provider business mailing address

10701 S EASTERN AVE APT 2618
HENDERSON NV
89052-4901
US

V. Phone/Fax

Practice location:
  • Phone: 702-629-4354
  • Fax: 702-644-0475
Mailing address:
  • Phone: 702-538-0230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMI4366
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: