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Individual

DR. THERESA A SPARKS

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
PH.D.

Contact information

Practice address
910 S 8TH ST STE 134, FERNANDINA BEACH, FL 32034-6700
(904) 891-4565
(904) 212-1216
Mailing address
2111 EGRET LN, FERNANDINA BEACH, FL 32034-4445
(904) 891-4565

Taxonomy

Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
PSY002794
GA
103TC0700X
Clinical Psychologist
Primary
PY9173
FL

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
699989780A
GA
Enumeration date
03/15/2006
Last updated
06/11/2019
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