Provider Demographics
NPI:1891866919
Name:SPARKS, REBECCA KYDD (MS)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:KYDD
Last Name:SPARKS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CHURCH ST
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4299
Mailing Address - Country:US
Mailing Address - Phone:802-658-9590
Mailing Address - Fax:
Practice Address - Street 1:2 CHURCH ST
Practice Address - Street 2:SUITE 2D
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4299
Practice Address - Country:US
Practice Address - Phone:802-658-9590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT5103OtherBCBS
VT1011661Medicaid