Provider Demographics
NPI:1801430988
Name:STARK, WADE M
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:M
Last Name:STARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2444
Mailing Address - Country:US
Mailing Address - Phone:217-345-7702
Mailing Address - Fax:217-345-7705
Practice Address - Street 1:626 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2444
Practice Address - Country:US
Practice Address - Phone:217-345-7702
Practice Address - Fax:217-345-7705
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
IL180013660101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional