Provider Demographics
NPI:1134285885
Name:LARK, JULIANNE S (PHD)
Entity Type:Individual
Prefix:DR
First Name:JULIANNE
Middle Name:S
Last Name:LARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4021 W MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-3706
Mailing Address - Country:US
Mailing Address - Phone:269-384-6055
Mailing Address - Fax:269-384-6056
Practice Address - Street 1:4021 W MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-3706
Practice Address - Country:US
Practice Address - Phone:269-384-6055
Practice Address - Fax:269-384-6056
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI6301008518103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301008518OtherPSYCHOLOGY LICENSE
MI68-0-C9-4634-0OtherBLUE CROSS BLUE SLD PIN