Provider Demographics
NPI:1063720191
Name:STARK, ALICE ELIZABETH (LICSW,MHP,CMHS, PHD)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:ELIZABETH
Last Name:STARK
Suffix:
Gender:F
Credentials:LICSW,MHP,CMHS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1805
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95927-1805
Mailing Address - Country:US
Mailing Address - Phone:530-447-2444
Mailing Address - Fax:
Practice Address - Street 1:1121 LABURNUM AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3465
Practice Address - Country:US
Practice Address - Phone:530-321-2595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CALCSW1056891041C0700X
WA606263551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2171336Medicaid