Provider Demographics
NPI:1588410104
Name:STARCK, LEE (EDS, MED, PCLC)
Entity type:Individual
Prefix:MR
First Name:LEE
Middle Name:
Last Name:STARCK
Suffix:
Gender:M
Credentials:EDS, MED, PCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3135 LODGEPOLE DR
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MT
Mailing Address - Zip Code:59870-4801
Mailing Address - Country:US
Mailing Address - Phone:715-607-0079
Mailing Address - Fax:
Practice Address - Street 1:405 S 1ST ST W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-1850
Practice Address - Country:US
Practice Address - Phone:406-541-8472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT65831101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional