MEDICARE: DR. THERESA A SPARKS PH.D.

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	103TC0700X	Clinical Psychologist	PSY002794	GA
2	103TC0700X	Clinical Psychologist	PY9173	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538138367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA A SPARKS PH.D.

Provider Business Mailing Address
First Line	:	2111 EGRET LN
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-4445
Country	:	US
Telephone Number	:	904-891-4565
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 S 8TH ST STE 134
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-6700
Country	:	US
Telephone Number	:	904-891-4565
Fax Number	:	904-212-1216

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

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	06/11/2019

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