Provider Demographics
NPI:1083829303
Name:STARK, LYNN LANEE (LMSW)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:LANEE
Last Name:STARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9254 VASSAR RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-9535
Mailing Address - Country:US
Mailing Address - Phone:989-723-5153
Mailing Address - Fax:
Practice Address - Street 1:9254 VASSAR RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-9535
Practice Address - Country:US
Practice Address - Phone:989-723-5153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010805961041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1022505Medicaid
MIN38810014Medicare Oscar/Certification