Provider Demographics
NPI:1952834517
Name:STARK, LAUREN MICHELLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MICHELLE
Last Name:STARK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MONASTERY AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-4857
Mailing Address - Country:US
Mailing Address - Phone:513-604-8686
Mailing Address - Fax:
Practice Address - Street 1:300 MONASTERY AVE APT 203
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-4857
Practice Address - Country:US
Practice Address - Phone:513-604-8686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA025934225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist