Provider Demographics
NPI:1275774788
Name:STARK, THERESA ROSE (LMT, BCTMB)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ROSE
Last Name:STARK
Suffix:
Gender:F
Credentials:LMT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 W 95TH STREET
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2034
Mailing Address - Country:US
Mailing Address - Phone:773-556-5333
Mailing Address - Fax:708-843-5811
Practice Address - Street 1:3850 W 95TH STREET
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2034
Practice Address - Country:US
Practice Address - Phone:773-556-5333
Practice Address - Fax:708-843-5811
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227-008050225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist