Provider Demographics
NPI:1215405360
Name:STARK, SCOTT DAVID (LPC)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:DAVID
Last Name:STARK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 W MICHIGAN AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-4025
Mailing Address - Country:US
Mailing Address - Phone:517-802-0501
Mailing Address - Fax:
Practice Address - Street 1:300 W WASHINGTON AVE STE 210B
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2160
Practice Address - Country:US
Practice Address - Phone:517-344-0913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health