Provider Demographics
NPI:1407613193
Name:STARK, ANN
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
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 1:4635 NICOLS RD # 104
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-3337
Mailing Address - Country:US
Mailing Address - Phone:612-289-6480
Mailing Address - Fax:
Practice Address - Street 1:4635 NICOLS RD # 104
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3337
Practice Address - Country:US
Practice Address - Phone:612-289-6480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician