Provider Demographics
NPI:1063573194
Name:STARK, KATHERINE JEAN (MPT, ATC)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:JEAN
Last Name:STARK
Suffix:
Gender:F
Credentials:MPT, ATC
Other - Prefix:MRS
Other - First Name:KATIE
Other - Middle Name:JEAN
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MPT, ATC
Mailing Address - Street 1:270 INTERNATIONAL CIR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1130
Mailing Address - Country:US
Mailing Address - Phone:408-972-6400
Mailing Address - Fax:
Practice Address - Street 1:270 INTERNATIONAL CIR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1130
Practice Address - Country:US
Practice Address - Phone:408-972-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22881225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist