Provider Demographics
NPI:1972817104
Name:KIMBERLY STARK, PSYD, LLC
Entity Type:Organization
Organization Name:KIMBERLY STARK, PSYD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:STARK-DICKASON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:740-751-7860
Mailing Address - Street 1:1339 1/2 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-5626
Mailing Address - Country:US
Mailing Address - Phone:740-751-7860
Mailing Address - Fax:
Practice Address - Street 1:1339 1/2 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-5626
Practice Address - Country:US
Practice Address - Phone:740-751-7860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6546103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty