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General NPI Number Information
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NPI Number | 1538138367
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Entity Type | Individual
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Provider Name | THERESA A SPARKS PH.D.
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Gender | Female
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Dates
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Enumeration Date | 03/15/2006
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 910 S 8TH ST STE 134
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City | FERNANDINA BEACH
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State | FL
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Zip | 32034-6700
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Country | US
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Telephone | 904-891-4565
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Fax | 904-212-1216
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Provider Business Mailing Address
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Address Line | 2111 EGRET LN
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City | FERNANDINA BEACH
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State | FL
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Zip | 32034-4445
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Country | US
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Telephone | 904-891-4565
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY002794
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY9173
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License Number State | FL
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