Provider Demographics
NPI:1679049258
Name:SPARK, SARAH KW
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:KW
Last Name:SPARK
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 1:65 N KELLER
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:WA
Mailing Address - Zip Code:99166
Mailing Address - Country:US
Mailing Address - Phone:509-775-3341
Mailing Address - Fax:509-775-2937
Practice Address - Street 1:65 N KELLER
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:WA
Practice Address - Zip Code:99166
Practice Address - Country:US
Practice Address - Phone:509-775-3341
Practice Address - Fax:509-775-2937
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60871216101Y00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor