Provider Demographics
NPI:1194468397
Name:SPARKS, KATRINA
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:SPARKS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 OAKFIELD DR STE 102
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-3893
Mailing Address - Country:US
Mailing Address - Phone:813-655-4166
Mailing Address - Fax:
Practice Address - Street 1:1463 OAKFIELD DR STE 102
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-3893
Practice Address - Country:US
Practice Address - Phone:813-655-4166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLBACB1006496106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist