Provider Demographics
NPI:1598196149
Name:STARK, HEIDI (MA, ATC)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6767 INDIAN LAKE RD NW
Mailing Address - Street 2:
Mailing Address - City:GARFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:56332-8403
Mailing Address - Country:US
Mailing Address - Phone:218-368-7792
Mailing Address - Fax:
Practice Address - Street 1:111 17TH AVE E
Practice Address - Street 2:SUITE 101
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-5273
Practice Address - Country:US
Practice Address - Phone:320-762-1144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer