Basic Information
| Provider Information | |||||||||
| NPI: | 1255331948 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUSAN SPARKS PHYSICAL THERAPY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 WILLIAMS ST | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012017463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134478070 | ||||||||
| FaxNumber: | 4134454918 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 WILLIAMS ST | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012017463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134478070 | ||||||||
| FaxNumber: | 4134454918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SPARKS | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4134478070 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 9769099 | 05 | MA | MEDICAID |