Provider Demographics
NPI:1982719399
Name:STARK, PATRICIA A (PHD, LP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:STARK
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 HUMBOLDT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-1953
Mailing Address - Country:US
Mailing Address - Phone:612-825-2685
Mailing Address - Fax:612-354-7398
Practice Address - Street 1:2908 HUMBOLDT AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-1953
Practice Address - Country:US
Practice Address - Phone:612-825-2685
Practice Address - Fax:612-354-7398
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0206103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical