Healthcare Provider Details

I. General information

NPI: 1720604259
Provider Name (Legal Business Name): DANIELLE SPARK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2020
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 PICASSO AVE STE A
DAVIS CA
95618-0546
US

IV. Provider business mailing address

1712 PICASSO AVE STE A
DAVIS CA
95618-0546
US

V. Phone/Fax

Practice location:
  • Phone: 530-219-1114
  • Fax:
Mailing address:
  • Phone: 530-219-1114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number65609
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: