Provider Demographics
NPI:1558606509
Name:STARK, SHELLY (OTR)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16671 TRINITY LOOP
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-4670
Mailing Address - Country:US
Mailing Address - Phone:858-220-9598
Mailing Address - Fax:
Practice Address - Street 1:16671 TRINITY LOOP
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-4670
Practice Address - Country:US
Practice Address - Phone:858-220-9598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1925225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist