Provider Demographics
NPI:1508371089
Name:STARK, KATHLEEN ROSE (LGSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ROSE
Last Name:STARK
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47940 MAYFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-2503
Mailing Address - Country:US
Mailing Address - Phone:301-769-1176
Mailing Address - Fax:
Practice Address - Street 1:21789 N CORAL DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653-5517
Practice Address - Country:US
Practice Address - Phone:240-237-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23467104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker