Provider Demographics
NPI:1679125900
Name:SPARKS, SUZANNE (COTA/L)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40071-6654
Mailing Address - Country:US
Mailing Address - Phone:317-308-1052
Mailing Address - Fax:
Practice Address - Street 1:401 LEWIS HARGETT CIR STE 120
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3564
Practice Address - Country:US
Practice Address - Phone:859-475-4305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251720224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant