Provider Demographics
NPI:1902219850
Name:STARK, ROHN TAYLOR JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROHN
Middle Name:TAYLOR
Last Name:STARK
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18631
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95158-8631
Mailing Address - Country:US
Mailing Address - Phone:808-283-0716
Mailing Address - Fax:
Practice Address - Street 1:4929 WILSHIRE BLVD STE 510
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3820
Practice Address - Country:US
Practice Address - Phone:562-904-3999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26386103T00000X
CAPSY26386103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist