Provider Demographics
NPI:1477185940
Name:SKILL SPARK THERAPY CENTER, PC
Entity Type:Organization
Organization Name:SKILL SPARK THERAPY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIESTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:715-531-5546
Mailing Address - Street 1:582 HAYWARD AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5378
Mailing Address - Country:US
Mailing Address - Phone:715-531-5546
Mailing Address - Fax:
Practice Address - Street 1:582 HAYWARD AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-5378
Practice Address - Country:US
Practice Address - Phone:715-531-5546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1700269925Medicaid