Provider Demographics
NPI:1477360600
Name:SPARKS OF LIGHT PSYCHOTHERAPY, PLLC
Entity type:Organization
Organization Name:SPARKS OF LIGHT PSYCHOTHERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLO PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:PAITTON
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:KENDRICK CALLERY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, ATR-P
Authorized Official - Phone:918-658-8352
Mailing Address - Street 1:123 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1223
Mailing Address - Country:US
Mailing Address - Phone:918-658-8352
Mailing Address - Fax:
Practice Address - Street 1:123 HARVARD AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1223
Practice Address - Country:US
Practice Address - Phone:918-658-8352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-11
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty