Provider Demographics
NPI:1356750475
Name:BARK, MARY KATHERYN (MS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERYN
Last Name:BARK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-4521
Mailing Address - Country:US
Mailing Address - Phone:206-550-9658
Mailing Address - Fax:
Practice Address - Street 1:612 E MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3726
Practice Address - Country:US
Practice Address - Phone:406-522-3722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-TMP-4087235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist