Provider Demographics
NPI:1992233548
Name:STARK, AMY JEAN
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JEAN
Last Name:STARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 GARDEN GATE DR # B
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-7471
Mailing Address - Country:US
Mailing Address - Phone:405-623-0988
Mailing Address - Fax:
Practice Address - Street 1:5601 NW 72ND ST STE 234
Practice Address - Street 2:
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73132-5920
Practice Address - Country:US
Practice Address - Phone:405-367-3927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-26
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
OK07094101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional