Provider Demographics
NPI:1619022191
Name:SPROULS, KATIE SARAH
Entity Type:Individual
Prefix:MS
First Name:KATIE
Middle Name:SARAH
Last Name:SPROULS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 S 114TH LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-9184
Mailing Address - Country:US
Mailing Address - Phone:623-478-1863
Mailing Address - Fax:
Practice Address - Street 1:15034 N PARKVIEW PL
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-6076
Practice Address - Country:US
Practice Address - Phone:623-876-7812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ710815OtherAHCCCS