Provider Demographics
NPI:1104679125
Name:BOOSE, SPARKALENA CRYSTAL (LLPC)
Entity type:Individual
Prefix:
First Name:SPARKALENA
Middle Name:CRYSTAL
Last Name:BOOSE
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3253 CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-3106
Mailing Address - Country:US
Mailing Address - Phone:989-475-4171
Mailing Address - Fax:
Practice Address - Street 1:3253 CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3106
Practice Address - Country:US
Practice Address - Phone:989-475-4171
Practice Address - Fax:989-393-6021
Is Sole Proprietor?:No
Enumeration Date:2024-04-09
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023496101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health