Provider Demographics
NPI:1730607771
Name:STARK, ETHAN ELLIOT (PSYD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:ELLIOT
Last Name:STARK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 S RIVER ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-5185
Mailing Address - Country:US
Mailing Address - Phone:630-844-2662
Mailing Address - Fax:
Practice Address - Street 1:3580 W MEDILL AVE APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2440
Practice Address - Country:US
Practice Address - Phone:608-335-6705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010910103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical