Provider Demographics
NPI:1568045599
Name:SCISSUM, SPARKLE A
Entity Type:Individual
Prefix:MRS
First Name:SPARKLE
Middle Name:A
Last Name:SCISSUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 S MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-2925
Mailing Address - Country:US
Mailing Address - Phone:330-318-3436
Mailing Address - Fax:
Practice Address - Street 1:238 S MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44509-2925
Practice Address - Country:US
Practice Address - Phone:330-318-3436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0900833104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker