Provider Demographics
NPI:1457500670
Name:STARK, TIMOTHY A
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:STARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84-275 MAKAHA VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-2130
Mailing Address - Country:US
Mailing Address - Phone:808-927-4084
Mailing Address - Fax:
Practice Address - Street 1:84-275 MAKAHA VALLEY RD
Practice Address - Street 2:
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-2130
Practice Address - Country:US
Practice Address - Phone:808-927-4084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist