Provider Demographics
NPI:1740506377
Name:STARK, REBECCA ANN
Entity type:Individual
Prefix:
First Name:REBECCA
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:PO BOX 230
Mailing Address - Street 2:214 E OAK
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74818-0230
Mailing Address - Country:US
Mailing Address - Phone:405-382-1112
Mailing Address - Fax:405-382-5747
Practice Address - Street 1:124 S BROADWAY AVE
Practice Address - Street 2:STE 408
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-5807
Practice Address - Country:US
Practice Address - Phone:580-332-8773
Practice Address - Fax:580-332-8774
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor