Provider Demographics
NPI:1134733454
Name:STARKE, MARY ROSE (MHC-LP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ROSE
Last Name:STARKE
Suffix:
Gender:F
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4770 SUNRISE HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-2911
Mailing Address - Country:US
Mailing Address - Phone:516-547-0749
Mailing Address - Fax:
Practice Address - Street 1:4770 SUNRISE HWY STE 102
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-2911
Practice Address - Country:US
Practice Address - Phone:516-547-0749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP09819101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health