Provider Demographics
NPI:1053942110
Name:INNERSPARKS,LLC
Entity type:Organization
Organization Name:INNERSPARKS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIVOLOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:OT/L
Authorized Official - Phone:608-836-0305
Mailing Address - Street 1:6310 STONEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3839
Mailing Address - Country:US
Mailing Address - Phone:608-516-7087
Mailing Address - Fax:
Practice Address - Street 1:1468 N HIGH POINT RD
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3683
Practice Address - Country:US
Practice Address - Phone:608-836-0305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI26-1173OtherSTATE LICENSE