Provider Demographics
NPI:1053020388
Name:STARK, VICTORIA LOUISE (R1488461122)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LOUISE
Last Name:STARK
Suffix:
Gender:F
Credentials:R1488461122
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:LOUISE
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18142 CASABA RD
Mailing Address - Street 2:
Mailing Address - City:ADELANTO
Mailing Address - State:CA
Mailing Address - Zip Code:92301-2061
Mailing Address - Country:US
Mailing Address - Phone:909-200-6073
Mailing Address - Fax:
Practice Address - Street 1:16248 VICTOR ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3934
Practice Address - Country:US
Practice Address - Phone:760-243-7151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)