Provider Demographics
NPI:1508015611
Name:SPARKS, JOHANNA GLEN (OT)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:GLEN
Last Name:SPARKS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1592 MECKLENBURG RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-9243
Mailing Address - Country:US
Mailing Address - Phone:607-592-3209
Mailing Address - Fax:
Practice Address - Street 1:1592 MECKLENBURG RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-9243
Practice Address - Country:US
Practice Address - Phone:607-592-3209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001684-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist