Provider Demographics
NPI:1912124793
Name:SPARKS, MARY E (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:SPARKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 TAMAL VISTA BLVD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1130
Mailing Address - Country:US
Mailing Address - Phone:415-453-5541
Mailing Address - Fax:
Practice Address - Street 1:21 TAMAL VISTA BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1130
Practice Address - Country:US
Practice Address - Phone:415-453-5541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 6101103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical