Provider Demographics
NPI:1699844472
Name:SPRAGUE, CARLA PORRETTA (MSW)
Entity Type:Individual
Prefix:MS
First Name:CARLA
Middle Name:PORRETTA
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5915 COPPERWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248
Mailing Address - Country:US
Mailing Address - Phone:972-385-1004
Mailing Address - Fax:
Practice Address - Street 1:2995 LBJ FRWY
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234
Practice Address - Country:US
Practice Address - Phone:972-620-1889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5197731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0040JNOtherBLUE CROSS BL SHIELD
TXS19773OtherCLINICAL SOC WORKER LIC
TX10008847OtherAMERIGROUP