Provider Demographics
NPI:1437687753
Name:SPARKS, MALLORY KING (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:KING
Last Name:SPARKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:MALLORY
Other - Middle Name:ELIZABETH
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:4901 MORENA BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-3370
Mailing Address - Country:US
Mailing Address - Phone:858-272-3992
Mailing Address - Fax:585-272-3804
Practice Address - Street 1:2300 W COMMERCE ST STE 306
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3841
Practice Address - Country:US
Practice Address - Phone:325-665-9306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX578641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical