Healthcare Provider Details

I. General information

NPI: 1275994543
Provider Name (Legal Business Name): SUSAN SPARKS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2016
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 N KNOXVILLE AVE
PEORIA IL
61615-2079
US

IV. Provider business mailing address

97 EASTGATE DR
WASHINGTON IL
61571-9271
US

V. Phone/Fax

Practice location:
  • Phone: 800-773-1682
  • Fax: 309-713-2898
Mailing address:
  • Phone: 800-773-1682
  • Fax: 309-713-2898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.016759
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number149.016759
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: