Provider Demographics
NPI:1629228671
Name:STARK, RAQUEL AYN (MA,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:RAQUEL
Middle Name:AYN
Last Name:STARK
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 TRISTAN LN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-4438
Mailing Address - Country:US
Mailing Address - Phone:716-626-0239
Mailing Address - Fax:
Practice Address - Street 1:25 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-3246
Practice Address - Country:US
Practice Address - Phone:585-343-1840
Practice Address - Fax:585-343-2185
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009875-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist