Provider Demographics
NPI:1902931447
Name:STARK, CHARLISA MARTRELL (PLPC)
Entity Type:Individual
Prefix:
First Name:CHARLISA
Middle Name:MARTRELL
Last Name:STARK
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARTRELL
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:18 PUCKETT RD
Mailing Address - Street 2:
Mailing Address - City:ELDON
Mailing Address - State:MO
Mailing Address - Zip Code:65026-4634
Mailing Address - Country:US
Mailing Address - Phone:573-280-5065
Mailing Address - Fax:
Practice Address - Street 1:108 W JASPER ST
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:MO
Practice Address - Zip Code:65084-1020
Practice Address - Country:US
Practice Address - Phone:573-378-6833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006033184101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional