Provider Demographics
NPI:1699464792
Name:SPARKWELL MENTAL HEALTH SERVICES LLC
Entity type:Organization
Organization Name:SPARKWELL MENTAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-828-9799
Mailing Address - Street 1:911 MCINTIRE ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2724
Mailing Address - Country:US
Mailing Address - Phone:901-828-9799
Mailing Address - Fax:
Practice Address - Street 1:911 MCINTIRE ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2724
Practice Address - Country:US
Practice Address - Phone:901-828-9799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty