Provider Demographics
NPI:1225349830
Name:STARBUCK, MISTY RAE (MOTR-L)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:RAE
Last Name:STARBUCK
Suffix:
Gender:F
Credentials:MOTR-L
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:RAE
Other - Last Name:MORTON-STARBUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:92 CUMBERLAND AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2648
Mailing Address - Country:US
Mailing Address - Phone:207-318-4681
Mailing Address - Fax:866-220-5031
Practice Address - Street 1:92 CUMBERLAND AVE APT 1
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2648
Practice Address - Country:US
Practice Address - Phone:207-318-4681
Practice Address - Fax:866-220-5031
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT2400225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1225349830OtherANTHEM OF MAINE
ME001634401Medicare PIN