Healthcare Provider Details

I. General information

NPI: 1871051110
Provider Name (Legal Business Name): ITZAMARA SPARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 PALOMAR AIRPORT RD STE 350
CARLSBAD CA
92011-1451
US

IV. Provider business mailing address

6411 REFLECTION DR APT 107
SAN DIEGO CA
92124-3192
US

V. Phone/Fax

Practice location:
  • Phone: 760-438-0078
  • Fax:
Mailing address:
  • Phone: 832-948-9595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-70870
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: