Healthcare Provider Details

I. General information

NPI: 1508582586
Provider Name (Legal Business Name): SPARK COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2022
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6303 4TH ST NW STE 1
LOS RANCHOS NM
87107-5855
US

IV. Provider business mailing address

1814 DON FELIPE RD SW
ALBUQUERQUE NM
87105-6654
US

V. Phone/Fax

Practice location:
  • Phone: 505-234-6166
  • Fax:
Mailing address:
  • Phone: 505-321-0906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARISA MANCINI ROTHROCK
Title or Position: BUSINESS OWNER
Credential: LPCC
Phone: 505-321-0906