Provider Demographics
NPI:1942767140
Name:SPARK COUNSELING CENTER, LLC
Entity Type:Organization
Organization Name:SPARK COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DODSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:504-300-9811
Mailing Address - Street 1:PO BOX 2937
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39505-2937
Mailing Address - Country:US
Mailing Address - Phone:504-300-9811
Mailing Address - Fax:800-416-3070
Practice Address - Street 1:3427 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3039
Practice Address - Country:US
Practice Address - Phone:504-300-9811
Practice Address - Fax:800-416-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-23
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty