Provider Demographics
NPI:1720604259
Name:SPARK, DANIELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:SPARK
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 1:1712 PICASSO AVE STE A
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-0546
Mailing Address - Country:US
Mailing Address - Phone:530-219-1114
Mailing Address - Fax:
Practice Address - Street 1:1712 PICASSO AVE STE A
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-0546
Practice Address - Country:US
Practice Address - Phone:530-219-1114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-20
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA656091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical