=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346927308
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMY J. STARK, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2023
-----------------------------------------------------
Last Update Date | 06/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9666 OLIVE BLVD STE 370
-----------------------------------------------------
City | OLIVETTE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63132-3025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-971-5272
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 729 CHIPPENDALE CT
-----------------------------------------------------
City | KIRKWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63122-5705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-971-5272
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST/MANAGER/SOLE MEMBER
-----------------------------------------------------
Name | AMY J. STARK
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 314-971-5272
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------