=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972817104
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIMBERLY STARK, PSYD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2010
-----------------------------------------------------
Last Update Date | 07/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1339 1/2 MOUNT VERNON AVE
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43302-5626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-751-7860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1339 1/2 MOUNT VERNON AVE
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43302-5626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-751-7860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. KIMBERLY ANN STARK-DICKASON
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 740-751-7860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 6546
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------