Basic Information
| Provider Information | |||||||||
| NPI: | 1952338022 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STARKS | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLOUNT | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2470 LONGSTONE LN STE K | ||||||||
| Address2: | |||||||||
| City: | MARRIOTTSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211041515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104422470 | ||||||||
| FaxNumber: | 4104422476 | ||||||||
| Practice Location | |||||||||
| Address1: | 2470 LONGSTONE LN STE K | ||||||||
| Address2: | |||||||||
| City: | MARRIOTTSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211041515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104422470 | ||||||||
| FaxNumber: | 4104422476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 19401 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 321566 | 01 | MD | MDIPA/OPTIMUM CHOICE | OTHER | OH15DL | 01 | DC | BC/BS | OTHER |