Provider Demographics
NPI:1629620828
Name:STARK, CASEY KYLYNN
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:KYLYNN
Last Name:STARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7048 COLUMNS CIR APT 107
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-3647
Mailing Address - Country:US
Mailing Address - Phone:952-807-3558
Mailing Address - Fax:
Practice Address - Street 1:7048 COLUMNS CIR APT 107
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-3647
Practice Address - Country:US
Practice Address - Phone:952-807-3558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist