=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508371089
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN ROSE STARK LGSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2017
-----------------------------------------------------
Last Update Date | 12/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21789 N CORAL DR
-----------------------------------------------------
City | LEXINGTON PARK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20653-5517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-237-8405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47940 MAYFLOWER DR
-----------------------------------------------------
City | LEXINGTON PARK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20653-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-769-1176
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 23467
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------