Active NPI
Ethan Elliot Stark, PSYD
- Clinical Psychologist
- Chicago, IL
National Provider Identifier
1730607771
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 071.010910
- Practice address
- 3580 W Medill Ave Apt 2
Chicago, IL 60647-2440 - Phone
- (608) 335-6705
- NPI assigned
- Aug 30, 2017
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 071.010910 | IL | Primary |
Addresses
Primary practice location
3580 W Medill Ave Apt 2
Chicago, IL 60647-2440
Mailing address
70 S River St
Aurora, IL 60506-5185
Phone (630) 844-2662
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 071.010910 | IL | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1504051200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1686182400000",
"number": "1730607771",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "70 S RIVER ST",
"city": "AURORA",
"state": "IL",
"postal_code": "605065185",
"telephone_number": "630-844-2662"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3580 W MEDILL AVE APT 2",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606472440",
"telephone_number": "608-335-6705"
}
],
"practiceLocations": [],
"basic": {
"last_name": "STARK",
"first_name": "ETHAN",
"middle_name": "ELLIOT",
"credential": "PSYD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2017-08-30",
"last_updated": "2023-06-08",
"certification_date": "2023-06-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "IL",
"license": "071.010910",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Chicago, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 8, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.