1033179171 NPI number — MRS. SUSAN WILKES SPARKS CCC/SLP

Table of content: MRS. SUSAN WILKES SPARKS CCC/SLP (NPI 1033179171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033179171 NPI number — MRS. SUSAN WILKES SPARKS CCC/SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPARKS
Provider First Name:
SUSAN
Provider Middle Name:
WILKES
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CCC/SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SPARKS
Provider Other First Name:
SUSAN
Provider Other Middle Name:
WILKES
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CCC/SLP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1033179171
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2228 STARLING ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31520-4200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-264-3141
Provider Business Mailing Address Fax Number:
912-264-6190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2228 STARLING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31520-4200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-264-3141
Provider Business Practice Location Address Fax Number:
912-264-6190
Provider Enumeration Date:
03/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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