Provider Demographics
NPI:1104176148
Name:STARK, CORTNY M (MA, LPCC, LADAC, CRC)
Entity type:Individual
Prefix:MS
First Name:CORTNY
Middle Name:M
Last Name:STARK
Suffix:
Gender:F
Credentials:MA, LPCC, LADAC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 INCA RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-7558
Mailing Address - Country:US
Mailing Address - Phone:505-452-7635
Mailing Address - Fax:
Practice Address - Street 1:1316 JACKIE RD SE STE 900
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:505-289-1042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCAD0171001101YA0400X
NM00165351103TR0400X
NMCCMH0198781101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation