Provider Demographics
NPI:1447404918
Name:STARK, KEVIN DOUGLAS (PHD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:STARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W 38TH ST STE 212
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6405
Mailing Address - Country:US
Mailing Address - Phone:512-324-3315
Mailing Address - Fax:512-324-3314
Practice Address - Street 1:1600 W 38TH ST STE 212
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6405
Practice Address - Country:US
Practice Address - Phone:512-324-3315
Practice Address - Fax:512-324-3314
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-3732103TB0200X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328753402Medicaid
TX328753403Medicaid
TX328753401Medicaid
TX317951YKYMMedicare PIN
TX328753403Medicaid