Healthcare Provider Details

I. General information

NPI: 1255258836
Provider Name (Legal Business Name): RYAN SPARKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 MANCHESTER DR
MASSAPEQUA NY
11758-1019
US

IV. Provider business mailing address

6942 199TH ST
FRESH MEADOWS NY
11365-4024
US

V. Phone/Fax

Practice location:
  • Phone: 516-531-3759
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP138939
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: