Provider Demographics
NPI:1609369396
Name:STARKS, REBECCA LEIGH (PMHNP-BC, RN)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:LEIGH
Last Name:STARKS
Suffix:
Gender:F
Credentials:PMHNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43902 WOODWARD AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-5022
Mailing Address - Country:US
Mailing Address - Phone:248-481-8428
Mailing Address - Fax:
Practice Address - Street 1:43902 WOODWARD AVE STE 230
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5022
Practice Address - Country:US
Practice Address - Phone:248-481-8428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704312286163WP0808X, 363LP0808X
MI4701312286363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1609369396Medicaid