Provider Demographics
NPI:1356916746
Name:STARKS, DOMINIQUE (LMT)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:STARKS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 56773
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72215-6773
Mailing Address - Country:US
Mailing Address - Phone:501-271-6224
Mailing Address - Fax:
Practice Address - Street 1:5 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-8405
Practice Address - Country:US
Practice Address - Phone:501-271-6224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT118471225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist