Provider Demographics
NPI:1245783141
Name:STARK, LAURA RAE (OTR/L)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:RAE
Last Name:STARK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2470 DANIELS BRIDGE RD
Practice Address - Street 2:BLDG 300
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6187
Practice Address - Country:US
Practice Address - Phone:706-389-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006194225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist