MEDICARE: MRS. LAURIE LYNN STARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1619530789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURIE LYNN STARK

Provider Business Mailing Address
First Line	:	7641 FOREST DR
Second Line	:
City	:	FISHERS
State	:	IN
Zip	:	46038-2214
Country	:	US
Telephone Number	:	317-529-5197
Fax Number	:

Provider Business Practice Location Address
First Line	:	1776 N MERIDIAN ST STE 300
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-1469
Country	:	US
Telephone Number	:	317-472-6137
Fax Number	:	317-604-8037

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2019
Last Update Date	:	04/15/2019

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