Provider Demographics
NPI:1710916143
Name:STARK, MARY KATHLEEN (ATC)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:KATHLEEN
Last Name:STARK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7559 SHERLOCK DR
Mailing Address - Street 2:
Mailing Address - City:ONSTED
Mailing Address - State:MI
Mailing Address - Zip Code:49265-9416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7559 SHERLOCK DR
Practice Address - Street 2:
Practice Address - City:ONSTED
Practice Address - State:MI
Practice Address - Zip Code:49265-9416
Practice Address - Country:US
Practice Address - Phone:517-605-1513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer