Provider Demographics
NPI:1952088791
Name:SPARKMAN, MADISON DOMINIQUE (MED)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:DOMINIQUE
Last Name:SPARKMAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N OAK PARK AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1364
Mailing Address - Country:US
Mailing Address - Phone:773-423-8447
Mailing Address - Fax:
Practice Address - Street 1:53 W JACKSON BLVD STE 604
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3448
Practice Address - Country:US
Practice Address - Phone:773-423-8447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health