Provider Demographics
NPI:1407179500
Name:SPARKS, MELLISA L (AT)
Entity type:Individual
Prefix:
First Name:MELLISA
Middle Name:L
Last Name:SPARKS
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5537 BLEAUX AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-0737
Mailing Address - Country:US
Mailing Address - Phone:479-872-5580
Mailing Address - Fax:479-872-5581
Practice Address - Street 1:1519 E PAGE AVE
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4521
Practice Address - Country:US
Practice Address - Phone:501-337-5600
Practice Address - Fax:501-337-5603
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor