Provider Demographics
NPI:1538374012
Name:STARK, JANELL ANN (CTRS)
Entity type:Individual
Prefix:MRS
First Name:JANELL
Middle Name:ANN
Last Name:STARK
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:MISS
Other - First Name:JANELL
Other - Middle Name:ANN
Other - Last Name:KEHRER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CTRS
Mailing Address - Street 1:21535 COLONY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1841
Mailing Address - Country:US
Mailing Address - Phone:586-774-4951
Mailing Address - Fax:
Practice Address - Street 1:35514 INDIGO DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4946
Practice Address - Country:US
Practice Address - Phone:586-212-2671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI50902225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist