Healthcare Provider Details

I. General information

NPI: 1942767140
Provider Name (Legal Business Name): SPARK COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2019
Last Update Date: 02/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3427 WASHINGTON AVE
GULFPORT MS
39507-3039
US

IV. Provider business mailing address

PO BOX 2937
GULFPORT MS
39505-2937
US

V. Phone/Fax

Practice location:
  • Phone: 504-300-9811
  • Fax: 800-416-3070
Mailing address:
  • Phone: 504-300-9811
  • Fax: 800-416-3070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARY DODSON
Title or Position: REGISTERED AGENT/OWNER
Credential: LMFT
Phone: 504-300-9811