Healthcare Provider Details

I. General information

NPI: 1346198918
Provider Name (Legal Business Name): SPARK VERSATILITY COLLECTIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2026
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 MARLTON PIKE E STE H41
CHERRY HILL NJ
08003-2153
US

IV. Provider business mailing address

1930 MARLTON PIKE E STE H41
CHERRY HILL NJ
08003-2153
US

V. Phone/Fax

Practice location:
  • Phone: 347-815-5866
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: PAULINE DAVID
Title or Position: MENTAL HEALTH CLINICIAN
Credential: LPC
Phone: 347-815-5866