Provider Demographics
NPI:1386978906
Name:STARK, MARY BETH (MSCCC-SLP)
Entity type:Individual
Prefix:MS
First Name:MARY BETH
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 NORTHEAST EXPY NE
Mailing Address - Street 2:SUITE 175
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2480
Mailing Address - Country:US
Mailing Address - Phone:404-386-1324
Mailing Address - Fax:
Practice Address - Street 1:1777 NORTHEAST EXPY NE
Practice Address - Street 2:SUITE 175
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2480
Practice Address - Country:US
Practice Address - Phone:404-386-1324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003069235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist