Provider Demographics
NPI:1316183080
Name:STARK, MICHELLE L (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:L
Last Name:STARK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 9TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-1548
Mailing Address - Country:US
Mailing Address - Phone:605-882-7700
Mailing Address - Fax:
Practice Address - Street 1:401 9TH AVE NW
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-1548
Practice Address - Country:US
Practice Address - Phone:605-882-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-30
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0427225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist