Provider Demographics
NPI:1568499747
Name:STARK, CAROLYN (PT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 BIRCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:MA
Mailing Address - Zip Code:01450-2078
Mailing Address - Country:US
Mailing Address - Phone:978-448-8405
Mailing Address - Fax:
Practice Address - Street 1:16 ARNOLD ST
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-2902
Practice Address - Country:US
Practice Address - Phone:401-765-2030
Practice Address - Fax:401-769-7472
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01878225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI09519OtherBC PROVIDER #