Provider Demographics
NPI:1770718629
Name:STARK-DICKASON, KIMBERLY ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANN
Last Name:STARK-DICKASON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:75 CLAIREDAN DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-8064
Mailing Address - Country:US
Mailing Address - Phone:614-396-5665
Mailing Address - Fax:614-396-5670
Practice Address - Street 1:75 CLAIREDAN DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-8064
Practice Address - Country:US
Practice Address - Phone:614-396-5665
Practice Address - Fax:614-396-5670
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6546103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent