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General NPI Number Information
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NPI Number | 1174887681
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Entity Type | Individual
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Provider Name | KEITH A STARK
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Gender | Male
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Dates
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Enumeration Date | 06/28/2012
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Last Update Date | 12/20/2018
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Provider Practice Location Address
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Address Line | 3450 E RUSSELL RD 210
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City | LAS VEGAS
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State | NV
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Zip | 89120-2201
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Country | US
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Telephone | 702-629-4354
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Fax | 702-644-0475
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Provider Business Mailing Address
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Address Line | 10701 S EASTERN AVE APT 2618
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City | HENDERSON
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State | NV
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Zip | 89052-4901
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Country | US
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Telephone | 702-538-0230
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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