Provider Demographics
NPI:1053972554
Name:STARK, AMY J (LCSW)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:J
Last Name:STARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12141 LADUE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8120
Mailing Address - Country:US
Mailing Address - Phone:314-336-1011
Mailing Address - Fax:314-878-4524
Practice Address - Street 1:12141 LADUE RD.
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8120
Practice Address - Country:US
Practice Address - Phone:314-336-1011
Practice Address - Fax:314-878-4524
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190202741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical