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General NPI Number Information
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NPI Number | 1538025382
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Entity Type | Organization
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Legal Business Name | SPARK THERAPY, LLC
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Dates
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Enumeration Date | 12/24/2025
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Last Update Date | 12/24/2025
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Provider Practice Location Address
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Address Line | 5289 YOUNGTON RD
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City | VICKSBURG
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State | MS
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Zip | 39183-7116
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Country | US
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Telephone | 601-618-1510
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Fax |
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Provider Business Mailing Address
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Address Line | 5289 YOUNGTON RD
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City | VICKSBURG
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State | MS
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Zip | 39183-7116
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Country | US
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Telephone | 601-618-1510
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | BETTY J CHILES
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Credential | RHIT
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Telephone | 601-618-5120
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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