Organization
SPARK THERAPY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BETTY J CHILES RHIT (CREDENTIALING SPECIALIST)
(601) 618-5120
Entity
Organization
Contact information
Practice address
5289 YOUNGTON RD, VICKSBURG, MS 39183-7116
(601) 618-1510
Mailing address
5289 YOUNGTON RD, VICKSBURG, MS 39183-7116
(601) 618-1510
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
007789524
—
MS
Enumeration date
12/24/2025
Last updated
12/24/2025
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