MEDICARE: MRS. THERESA AMANDA STARK PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1215116181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. THERESA AMANDA STARK PTA

Provider Business Mailing Address
First Line	:	522 KAYLYNN ST SE
Second Line	:
City	:	MASSILLON
State	:	OH
Zip	:	44646-7060
Country	:	US
Telephone Number	:	330-834-0427
Fax Number	:

Provider Business Practice Location Address
First Line	:	513 E MAIN ST
Second Line	:
City	:	LOUISVILLE
State	:	OH
Zip	:	44641-1421
Country	:	US
Telephone Number	:	330-875-0888
Fax Number	:	330-875-4922

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/29/2007
Last Update Date	:	10/29/2007

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