| Theresa A. Sparks, Ph.d., Inc. | |
|
910 S 8th St Ste 134 Fernandina Beach FL 32034-6700 | |
| (904) 891-4565 | |
| (904) 212-1216 |
| Full Name | Theresa A. Sparks, Ph.d., Inc. |
|---|---|
| Speciality | Psychologist |
| Location | 910 S 8th St Ste 134, Fernandina Beach, Florida |
| Authorized Official Name and Position | Theresa A Sparks (PRESIDENT/OWNER) |
| Authorized Official Contact | 9048914565 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Theresa A. Sparks, Ph.d., Inc. 910 S 8th St Ste 134 Fernandina Beach FL 32034-6700 Ph: (904) 891-4565 | Theresa A. Sparks, Ph.d., Inc. 910 S 8th St Ste 134 Fernandina Beach FL 32034-6700 Ph: (904) 891-4565 |
| NPI Number | 1679955181 |
|---|---|
| Provider Enumeration Date | 06/20/2015 |
| Last Update Date | 06/11/2019 |
| Medicare PECOS PAC ID | 4486964327 |
|---|---|
| Medicare Enrollment ID | O20151105001623 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1679955181 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | PY9173 (Florida) | Primary |
| 103TC0700X | Psychologist - Clinical | PSY002794 (Georgia) | Secondary |
| Provider Name | Theresa A Sparks |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1538138367 PECOS PAC ID: 5193035038 Enrollment ID: I20151105001749 |
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