Provider Demographics
NPI:1073203832
Name:STARK, MADELIN M
Entity Type:Individual
Prefix:
First Name:MADELIN
Middle Name:M
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 1:300 BROADWAY N APT 401
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4726
Mailing Address - Country:US
Mailing Address - Phone:701-361-4721
Mailing Address - Fax:
Practice Address - Street 1:110 S WALNUT AVE
Practice Address - Street 2:
Practice Address - City:LUVERNE
Practice Address - State:MN
Practice Address - Zip Code:56156-1781
Practice Address - Country:US
Practice Address - Phone:507-283-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist