Provider Demographics
NPI:1477861565
Name:SPARKS, SUSAN (OTR)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5211 79TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-2832
Mailing Address - Country:US
Mailing Address - Phone:806-853-9740
Mailing Address - Fax:
Practice Address - Street 1:5211 79TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-2832
Practice Address - Country:US
Practice Address - Phone:806-535-3238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2825225X00000X
TX113347225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist