Healthcare Provider Details

I. General information

NPI: 1265075105
Provider Name (Legal Business Name): BETTY SPARKS ACIERNO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1353 SW HEATHER TER
STUART FL
34997-7106
US

IV. Provider business mailing address

1353 SW HEATHER TER
STUART FL
34997-7106
US

V. Phone/Fax

Practice location:
  • Phone: 772-284-2774
  • Fax:
Mailing address:
  • Phone: 772-284-2774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12905
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: