Healthcare Provider Details

I. General information

NPI: 1992617963
Provider Name (Legal Business Name): SPARK CHANGE WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 GAMBRILLS RD STE 4B
GAMBRILLS MD
21054-1141
US

IV. Provider business mailing address

331 GAMBRILLS RD STE 4B
GAMBRILLS MD
21054-1141
US

V. Phone/Fax

Practice location:
  • Phone: 410-864-0201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: RENEE MACK
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 302-898-1720