Provider Demographics
NPI:1528431210
Name:SPARKS, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4142 E US HIGHWAY 136
Mailing Address - Street 2:
Mailing Address - City:PITTSBORO
Mailing Address - State:IN
Mailing Address - Zip Code:46167-9046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:651 TAYLOR DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-7246
Practice Address - Country:US
Practice Address - Phone:937-352-1269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer