Healthcare Provider Details

I. General information

NPI: 1902931447
Provider Name (Legal Business Name): CHARLISA MARTRELL STARK PLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARTRELL STARK

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W JASPER ST
VERSAILLES MO
65084-1020
US

IV. Provider business mailing address

18 PUCKETT RD
ELDON MO
65026-4634
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-6833
  • Fax:
Mailing address:
  • Phone: 573-280-5065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2006033184
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: