Provider Demographics
NPI:1992411334
Name:SPARKS, MARK (LCSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SPARKS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 WHITLAND WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5953
Mailing Address - Country:US
Mailing Address - Phone:954-540-9752
Mailing Address - Fax:
Practice Address - Street 1:721 A1A BEACH BLVD STE 7
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-6737
Practice Address - Country:US
Practice Address - Phone:904-844-8308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW20968101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health