Provider Demographics
NPI:1043631302
Name:SPARKS, KIMBERLY ELIZABETH (CDP)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ELIZABETH
Last Name:SPARKS
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ELIZABETH
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12201 PACIFIC AVE S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-5126
Mailing Address - Country:US
Mailing Address - Phone:253-536-6425
Mailing Address - Fax:
Practice Address - Street 1:12201 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-5126
Practice Address - Country:US
Practice Address - Phone:253-536-6425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60097366101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP60097366OtherWASHINGTON STATE DEPARTMENT OF HEALTH