Provider Demographics
NPI:1609290709
Name:SPARKMAN, GWEN (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:SPARKMAN
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 NICHOLSON FARM RD
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-2814
Mailing Address - Country:US
Mailing Address - Phone:706-897-5489
Mailing Address - Fax:
Practice Address - Street 1:185 NICHOLSON FARM RD
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-2814
Practice Address - Country:US
Practice Address - Phone:706-897-5489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14127235Z00000X
GASLP007736235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist