Provider Demographics
NPI:1801809033
Name:STARK, PATRICIA ANN (PH D)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:ANN
Last Name:STARK
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2802 MARYVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062
Mailing Address - Country:US
Mailing Address - Phone:618-345-6632
Mailing Address - Fax:
Practice Address - Street 1:2802 MARYVILLE ROAD
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062
Practice Address - Country:US
Practice Address - Phone:618-345-6632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL115374OtherHEALTHLINK
MO115374OtherHEALTHLINK
ID06072005OtherBLUE CROSS BLUE SHIELD