Healthcare Provider Details

I. General information

NPI: 1992411334
Provider Name (Legal Business Name): MARK SPARKS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 01/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 A1A BEACH BLVD STE 7
SAINT AUGUSTINE FL
32080-6737
US

IV. Provider business mailing address

240 WHITLAND WAY
SAINT AUGUSTINE FL
32086-5953
US

V. Phone/Fax

Practice location:
  • Phone: 904-844-8308
  • Fax:
Mailing address:
  • Phone: 954-540-9752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW20968
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: