Provider Demographics
NPI:1114185543
Name:SPARKS, MAGGIE DIANE (MA,)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:DIANE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:MA,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 S DIVISION ST STE A
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-1701
Mailing Address - Country:US
Mailing Address - Phone:573-723-1100
Mailing Address - Fax:573-723-1130
Practice Address - Street 1:11 S DIVISION ST STE A
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-1701
Practice Address - Country:US
Practice Address - Phone:573-723-1100
Practice Address - Fax:573-723-1130
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009032464101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional