Basic Information
| Provider Information | |||||||||
| NPI: | 1699163816 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPARKS | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LEAH | ||||||||
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| Credential: | LSW, NCC, LPCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 411 COURT ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456623932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403548004 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 411 COURT ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403546685 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2014 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 166698 | KY | N | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | C.1902344 | OH | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | QMHS | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | CMS | OH | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | E.20011683 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0375975 | 05 | OH | MEDICAID |