Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 987 | ND |
Y | 225XP0200X | Occupational Therapist - Pediatrics | 987 | ND |
NPI | 1265837991 |
---|---|
Provider Name | Katie Stark |
First Address | Grafton, ND 58237-2036 |
Second Address | Grand Forks, ND 58201-6342 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2014 |
Last Update Date | 23/10/2014 |