Provider Demographics
NPI:1508325176
Name:SPARKS, STACEY (LPC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:MAROA
Mailing Address - State:IL
Mailing Address - Zip Code:61756-9220
Mailing Address - Country:US
Mailing Address - Phone:217-433-3002
Mailing Address - Fax:
Practice Address - Street 1:410 W LINCOLN ST
Practice Address - Street 2:
Practice Address - City:MAROA
Practice Address - State:IL
Practice Address - Zip Code:61756-9220
Practice Address - Country:US
Practice Address - Phone:217-433-3002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178005202101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional