Provider Demographics
NPI:1134293368
Name:SPARKS, ANGELA O'NEILL (OTRL)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:O'NEILL
Last Name:SPARKS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:KAYE
Other - Last Name:SPARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:452 HIGHWAY 53 E UNIT 2191
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-4197
Mailing Address - Country:US
Mailing Address - Phone:404-436-0774
Mailing Address - Fax:
Practice Address - Street 1:40 GROGAN DR STE 110
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-1004
Practice Address - Country:US
Practice Address - Phone:404-436-0774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1721225X00000X
GAOT005505225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02983026Medicaid