Provider Demographics
NPI:1538138367
Name:SPARKS, THERESA A (PHD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:A
Last Name:SPARKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 EGRET LN
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-4445
Mailing Address - Country:US
Mailing Address - Phone:904-891-4565
Mailing Address - Fax:
Practice Address - Street 1:910 S 8TH ST STE 134
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-6700
Practice Address - Country:US
Practice Address - Phone:904-891-4565
Practice Address - Fax:904-212-1216
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002794103TC0700X
FLPY9173103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA699989780AMedicaid