Provider Demographics
NPI:1114232188
Name:STARK, PATTY L (BA MS EDS)
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:L
Last Name:STARK
Suffix:
Gender:F
Credentials:BA MS EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W COLFAX ST
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MO
Mailing Address - Zip Code:64625-9608
Mailing Address - Country:US
Mailing Address - Phone:660-644-5715
Mailing Address - Fax:660-644-5710
Practice Address - Street 1:400 W COLFAX ST
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MO
Practice Address - Zip Code:64625-9608
Practice Address - Country:US
Practice Address - Phone:660-644-5715
Practice Address - Fax:660-644-5710
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist