MEDICARE: SPARK WELLNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1366131559
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARK WELLNESS

Provider Business Mailing Address
First Line	:	102 STAUFFER RD
Second Line	:
City	:	SEVERNA PARK
State	:	MD
Zip	:	21146-3021
Country	:	US
Telephone Number	:	410-245-2199
Fax Number	:

Provider Business Practice Location Address
First Line	:	692B RITCHIE HWY STE 101
Second Line	:
City	:	SEVERNA PARK
State	:	MD
Zip	:	21146-3938
Country	:	US
Telephone Number	:	410-245-2199
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	STEPHANIE HIBBARD
Credential	:
Telephone Number	:	410-245-2199

Provider Enumeration Date	:	05/03/2023
Last Update Date	:	05/03/2023

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Directions to “SPARK WELLNESS ” Practice Location

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