Provider Demographics
NPI:1073732947
Name:SPARKS, KELLY (MACCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4928 CINDERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-2118
Mailing Address - Country:US
Mailing Address - Phone:405-350-2654
Mailing Address - Fax:
Practice Address - Street 1:4928 CINDERWOOD DR
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-2118
Practice Address - Country:US
Practice Address - Phone:405-350-2654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2975235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist