Provider Demographics
NPI:1447681788
Name:DR. JULIANNE S. LARK, PLC
Entity type:Organization
Organization Name:DR. JULIANNE S. LARK, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIANNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:LARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:269-384-6055
Mailing Address - Street 1:4021 W MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-3706
Mailing Address - Country:US
Mailing Address - Phone:269-384-6055
Mailing Address - Fax:269-384-6056
Practice Address - Street 1:4021 W MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-3706
Practice Address - Country:US
Practice Address - Phone:269-384-6055
Practice Address - Fax:269-384-6056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008518103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68-0-C9-4634-0OtherBLUE CROSS BLUE SHIELD PIN