Provider Demographics
NPI:1780237834
Name:STARKS, STEPHANIE MARIE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:STARKS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 WILD DUNES PATH
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49127-9397
Mailing Address - Country:US
Mailing Address - Phone:269-930-4112
Mailing Address - Fax:
Practice Address - Street 1:230 COLLINGWOOD ST STE 250
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3845
Practice Address - Country:US
Practice Address - Phone:248-581-8777
Practice Address - Fax:888-975-9374
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011141891041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1780237834Medicaid