Provider Demographics
NPI:1386465953
Name:SPARK OF LIFE THERAPY LLC
Entity type:Organization
Organization Name:SPARK OF LIFE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SLPA
Authorized Official - Prefix:
Authorized Official - First Name:MIRAIDYS
Authorized Official - Middle Name:D
Authorized Official - Last Name:HIDALGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-477-1486
Mailing Address - Street 1:6781 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-3936
Mailing Address - Country:US
Mailing Address - Phone:954-477-1486
Mailing Address - Fax:
Practice Address - Street 1:6781 SCOTT ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-3936
Practice Address - Country:US
Practice Address - Phone:954-477-1486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty