Healthcare Provider Details

I. General information

NPI: 1649965591
Provider Name (Legal Business Name): TINA REBECCA SPARKS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 RIO RANCHO BLVD NE STE 200
RIO RANCHO NM
87124-1458
US

IV. Provider business mailing address

206 SANTA ELENA RD SE
RIO RANCHO NM
87124-1307
US

V. Phone/Fax

Practice location:
  • Phone: 505-814-1460
  • Fax:
Mailing address:
  • Phone: 314-276-8728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCTB-2023-0074
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: