Provider Demographics
NPI:1508582586
Name:SPARK COUNSELING LLC
Entity Type:Organization
Organization Name:SPARK COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARISA
Authorized Official - Middle Name:MANCINI
Authorized Official - Last Name:ROTHROCK
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-321-0906
Mailing Address - Street 1:1814 DON FELIPE RD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-6654
Mailing Address - Country:US
Mailing Address - Phone:505-321-0906
Mailing Address - Fax:
Practice Address - Street 1:6303 4TH ST NW STE 1
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-5855
Practice Address - Country:US
Practice Address - Phone:505-234-6166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty