Provider Demographics
NPI:1366299802
Name:STARK, SHELBY MARIE (COTA/L)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:MARIE
Last Name:STARK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:MARIE
Other - Last Name:HOTOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:155 PCR 912
Mailing Address - Street 2:
Mailing Address - City:SAINT MARY
Mailing Address - State:MO
Mailing Address - Zip Code:63673-7113
Mailing Address - Country:US
Mailing Address - Phone:573-768-9458
Mailing Address - Fax:
Practice Address - Street 1:2400 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-9620
Practice Address - Country:US
Practice Address - Phone:573-290-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012018295224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant