Healthcare Provider Details

I. General information

NPI: 1710618384
Provider Name (Legal Business Name): KRISTIN SPARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 S PATTERSON BLVD
DAYTON OH
45402-2624
US

IV. Provider business mailing address

100 CROWNE POINT PL
CINCINNATI OH
45241-5427
US

V. Phone/Fax

Practice location:
  • Phone: 937-966-4673
  • Fax:
Mailing address:
  • Phone: 513-743-7628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.184009
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: