Provider Demographics
NPI:1447405790
Name:SPARKS, COURTNIE BROOKE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:COURTNIE
Middle Name:BROOKE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:COURTNIE
Other - Middle Name:BROOKE
Other - Last Name:RUTHERFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:2405 ATHERHOLT RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2184
Mailing Address - Country:US
Mailing Address - Phone:434-485-8500
Mailing Address - Fax:434-485-8599
Practice Address - Street 1:2405 ATHERHOLT RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2184
Practice Address - Country:US
Practice Address - Phone:434-485-8500
Practice Address - Fax:434-485-8599
Is Sole Proprietor?:No
Enumeration Date:2008-11-28
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1447405790Medicaid
VAMC12809Medicare PIN
VA1447405790Medicaid
P01584732Medicare PIN