Provider Demographics
NPI:1730547811
Name:STARK, MYRA ANN (MSW)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:ANN
Last Name:STARK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:ANN
Other - Last Name:SANDFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:185 44TH ST SW STE B
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-3363
Mailing Address - Country:US
Mailing Address - Phone:616-244-2246
Mailing Address - Fax:616-244-2247
Practice Address - Street 1:185 44TH ST SW STE B
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-3363
Practice Address - Country:US
Practice Address - Phone:616-244-2246
Practice Address - Fax:616-244-2247
Is Sole Proprietor?:No
Enumeration Date:2016-02-04
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801104031104100000X
390200000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801104031Medicaid