MEDICARE: KEITH A STARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MI4366	NV

General Provider Information

NPI Number	:	1174887681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH A STARK

Provider Business Mailing Address
First Line	:	10701 S EASTERN AVE APT 2618
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-4901
Country	:	US
Telephone Number	:	702-538-0230
Fax Number	:

Provider Business Practice Location Address
First Line	:	3450 E RUSSELL RD
Second Line	:	210
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-2201
Country	:	US
Telephone Number	:	702-629-4354
Fax Number	:	702-644-0475

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2012
Last Update Date	:	06/24/2026

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Directions to “ KEITH A STARK ” Practice Location

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