Provider Demographics
NPI:1659560043
Name:SPARKS, PAMELA GAIL (LCSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:GAIL
Last Name:SPARKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-7301
Mailing Address - Country:US
Mailing Address - Phone:918-759-2100
Mailing Address - Fax:918-759-2150
Practice Address - Street 1:106 W 5TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-7301
Practice Address - Country:US
Practice Address - Phone:918-759-2100
Practice Address - Fax:918-759-2150
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK45651041C0700X
OK725101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK300522336OtherMEDICARE