Healthcare Provider Details

I. General information

NPI: 1093105678
Provider Name (Legal Business Name): AMANDA J. STARK M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2015
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 GLENDON CT
DUBLIN OH
43016-3246
US

IV. Provider business mailing address

PO BOX 182848
COLUMBUS OH
43218-2848
US

V. Phone/Fax

Practice location:
  • Phone: 877-641-2010
  • Fax: 614-822-3929
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number00096802
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: