Provider Demographics
NPI:1437651247
Name:SPARKS, STACEY LYNN (LMHC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:SPARKS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 FERN ST
Mailing Address - Street 2:
Mailing Address - City:BALDWINVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01436-1354
Mailing Address - Country:US
Mailing Address - Phone:508-963-9526
Mailing Address - Fax:
Practice Address - Street 1:12 FERN STREET
Practice Address - Street 2:
Practice Address - City:BALDWINVILLE
Practice Address - State:MA
Practice Address - Zip Code:01436
Practice Address - Country:US
Practice Address - Phone:508-963-9526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA311195101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health