Provider Demographics
NPI:1528320181
Name:STARK, NICOLE MARIE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:STARK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:RUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:8606 ALLISONVILLE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-3585
Mailing Address - Country:US
Mailing Address - Phone:317-951-9358
Mailing Address - Fax:317-663-2524
Practice Address - Street 1:66 WEST ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-5861
Practice Address - Country:US
Practice Address - Phone:413-343-4264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW1281641041C0700X
IN34007088A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical