Provider Demographics
NPI:1457506776
Name:STARK, EILEEN (MA/OTR)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:MA/OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 TROLLEY RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:NY
Mailing Address - Zip Code:10548-1129
Mailing Address - Country:US
Mailing Address - Phone:914-737-5854
Mailing Address - Fax:914-737-5191
Practice Address - Street 1:85 TROLLEY RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:NY
Practice Address - Zip Code:10548-1129
Practice Address - Country:US
Practice Address - Phone:914-737-5854
Practice Address - Fax:914-737-5191
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYSOT 005893172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005893OtherNYSOT