Provider Demographics
NPI:1497846273
Name:SPARKS, CODY G (LMLP & LCP)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:G
Last Name:SPARKS
Suffix:
Gender:M
Credentials:LMLP & LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66505-0747
Mailing Address - Country:US
Mailing Address - Phone:785-587-4300
Mailing Address - Fax:785-587-4377
Practice Address - Street 1:814 CAROLINE AVE
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441-5210
Practice Address - Country:US
Practice Address - Phone:785-762-5250
Practice Address - Fax:785-762-2144
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0133103T00000X
KS131103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100229020AMedicaid
KS840687OtherBCBS