Provider Demographics
NPI:1700550381
Name:STARKS, CHANDLER (LCMT)
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:
Last Name:STARKS
Suffix:
Gender:F
Credentials:LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4069 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409-1841
Mailing Address - Country:US
Mailing Address - Phone:773-988-0438
Mailing Address - Fax:
Practice Address - Street 1:4069 LOUISIANA ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-1841
Practice Address - Country:US
Practice Address - Phone:773-988-0438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227021219225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0Medicaid