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General NPI Number Information
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NPI Number | 1215405360
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Entity Type | Individual
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Provider Name | SCOTT DAVID STARK LPC
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Gender | Male
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Dates
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Enumeration Date | 11/07/2018
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Last Update Date | 11/11/2024
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Provider Practice Location Address
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Address Line | 300 W WASHINGTON AVE STE 210B
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City | JACKSON
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State | MI
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Zip | 49201-2160
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Country | US
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Telephone | 517-344-0913
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Fax |
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Provider Business Mailing Address
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Address Line | 1508 W MICHIGAN AVE APT 1
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City | JACKSON
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State | MI
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Zip | 49202-4025
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Country | US
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Telephone | 517-802-0501
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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