Provider Demographics
NPI:1649574781
Name:STARK, LISA ANN
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:STARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6288 US HIGHWAY 441 SE
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-2350
Mailing Address - Country:US
Mailing Address - Phone:863-467-0511
Mailing Address - Fax:863-763-7346
Practice Address - Street 1:6288 US HIGHWAY 441 SE
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34974-2350
Practice Address - Country:US
Practice Address - Phone:863-467-0511
Practice Address - Fax:863-763-7346
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool