Provider Demographics
NPI:1861714453
Name:SPARKS, DANIELLE GRACE (OTR)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:GRACE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:GRACE
Other - Last Name:MALED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:8501 HARCOURT RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2046
Mailing Address - Country:US
Mailing Address - Phone:317-875-9501
Mailing Address - Fax:317-808-8802
Practice Address - Street 1:8501 HARCOURT RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2046
Practice Address - Country:US
Practice Address - Phone:317-875-9105
Practice Address - Fax:317-808-8802
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004912A225XH1200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN062110018OtherMEDICARE PTAN
IN201028770Medicaid