Basic Information
Provider Information | |||||||||
NPI: | 1720064769 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPARKS | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1010 MAIN ST S | ||||||||
Address2: |   | ||||||||
City: | MC KEE | ||||||||
State: | KY | ||||||||
PostalCode: | 404477089 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6062877104 | ||||||||
FaxNumber: | 6062874409 | ||||||||
Practice Location | |||||||||
Address1: | 104 LEGACY DR | ||||||||
Address2: |   | ||||||||
City: | BEREA | ||||||||
State: | KY | ||||||||
PostalCode: | 404039594 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8599862323 | ||||||||
FaxNumber: | 8599867728 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2005 | ||||||||
LastUpdateDate: | 11/27/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1592 | KY | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 82000373 | 05 | KY |   | MEDICAID |