Provider Demographics
NPI:1770619900
Name:SPARKS, DAVINE S (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:DAVINE
Middle Name:S
Last Name:SPARKS
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6302 STABLEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-8975
Mailing Address - Country:US
Mailing Address - Phone:678-232-2765
Mailing Address - Fax:
Practice Address - Street 1:2828 WESLEY CHAPEL RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-2313
Practice Address - Country:US
Practice Address - Phone:678-232-2765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0015551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical