Healthcare Provider Details

I. General information

NPI: 1225278229
Provider Name (Legal Business Name): CHRISTINE LOUISE SPARKS O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 N FODALE AVE
SOUTHPORT NC
28461-3538
US

IV. Provider business mailing address

630 N FODALE AVE
SOUTHPORT NC
28461-3538
US

V. Phone/Fax

Practice location:
  • Phone: 910-457-0830
  • Fax:
Mailing address:
  • Phone: 910-457-0830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6146
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31002164A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number6146
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number31002164A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: