Provider Demographics
NPI:1457942567
Name:SPARKS, ROCHELLE NICOLE
Entity type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:NICOLE
Last Name:SPARKS
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 1:117 GRANARY APT 107
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-5282
Mailing Address - Country:US
Mailing Address - Phone:220-242-0706
Mailing Address - Fax:
Practice Address - Street 1:5815 WESTBOURNE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1459
Practice Address - Country:US
Practice Address - Phone:833-510-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175152101YA0400X
OHS.2410807104100000X
OHCDCA.178777101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03347737Medicaid