Provider Demographics
NPI:1497995930
Name:STARK, GLENDA R (LMSW)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:R
Last Name:STARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:GLENDA
Other - Middle Name:K
Other - Last Name:RENNIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA
Mailing Address - Street 1:2150 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38127-6662
Mailing Address - Country:US
Mailing Address - Phone:901-353-5440
Mailing Address - Fax:901-353-5464
Practice Address - Street 1:2150 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38127-6662
Practice Address - Country:US
Practice Address - Phone:901-353-5440
Practice Address - Fax:901-353-5464
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6599104100000X
TN51011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker