Provider Demographics
NPI:1275994543
Name:SPARKS, SUSAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 EASTGATE DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9271
Mailing Address - Country:US
Mailing Address - Phone:800-773-1682
Mailing Address - Fax:309-713-2898
Practice Address - Street 1:8500 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2079
Practice Address - Country:US
Practice Address - Phone:800-773-1682
Practice Address - Fax:309-713-2898
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0167591041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical