Provider Demographics
NPI:1598422883
Name:SPARKS, GRANT DEVON
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:DEVON
Last Name:SPARKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 TURNBRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-6505
Mailing Address - Country:US
Mailing Address - Phone:770-312-2733
Mailing Address - Fax:
Practice Address - Street 1:3720 CHAMBLEE DUNWOODY RD STE D2
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-2064
Practice Address - Country:US
Practice Address - Phone:678-802-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-21
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health