Provider Demographics
NPI:1235301177
Name:SPARKS, TRACEY LYNN (COTA/L)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:SPARKS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 EAGLES CREST AVENUE
Mailing Address - Street 2:F-6
Mailing Address - City:DAVENPORT
Mailing Address - State:IL
Mailing Address - Zip Code:52804-3652
Mailing Address - Country:US
Mailing Address - Phone:309-635-0454
Mailing Address - Fax:
Practice Address - Street 1:1701 EAGLES CREST AVE
Practice Address - Street 2:F-6
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-5083
Practice Address - Country:US
Practice Address - Phone:309-635-0454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant