Provider Demographics
NPI:1003025966
Name:SPARKS, LAURA J (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:SPARKS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 GLENRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-0200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MOUNTAIN VIEW DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2434
Practice Address - Country:US
Practice Address - Phone:770-889-2163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008014225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist