Provider Demographics
NPI:1528438546
Name:STARK, AMY (NCSP)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 HERNDON PKWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-5233
Mailing Address - Country:US
Mailing Address - Phone:703-467-9036
Mailing Address - Fax:
Practice Address - Street 1:462 HERNDON PKWY
Practice Address - Street 2:SUITE 202
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-5233
Practice Address - Country:US
Practice Address - Phone:703-467-9036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0803000213103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool