Provider Demographics
NPI:1811339039
Name:SPARKS, EMILY ROSE (MSW, LICSW)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:ROSE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ROSE
Other - Last Name:MENART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LICSW
Mailing Address - Street 1:55 FRUIT ST.
Mailing Address - Street 2:WAC 817
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:857-331-3431
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST.
Practice Address - Street 2:WAC 817
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:857-331-3431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA1206841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program