Healthcare Provider Details

I. General information

NPI: 1477711828
Provider Name (Legal Business Name): KATHY JEAN SPARKS M.S.,L.L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2008
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32910 W 13 MILE RD SUITE D-402
FARMINGTON HILLS MI
48334-1980
US

IV. Provider business mailing address

44736 HUNTINGTON DR
NOVI MI
48375-2220
US

V. Phone/Fax

Practice location:
  • Phone: 248-737-4616
  • Fax:
Mailing address:
  • Phone: 248-349-0549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number6301009986
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: