MEDICARE: SPARROW CARE PSYCHOTHERAPY, LLC

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	106H00000X	Marriage & Family Therapist	5960	SC

General Provider Information

NPI Number	:	1861879439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARROW CARE PSYCHOTHERAPY, LLC

Provider Business Mailing Address
First Line	:	1974 CAROLINA PLACE DR
Second Line	:	200A
City	:	FORT MILL
State	:	SC
Zip	:	29708-6923
Country	:	US
Telephone Number	:	855-542-8255
Fax Number	:

Provider Business Practice Location Address
First Line	:	1974 CAROLINA PLACE DR
Second Line	:	200A
City	:	FORT MILL
State	:	SC
Zip	:	29708-6923
Country	:	US
Telephone Number	:	855-542-8255
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOTHERAPIST
Name	:	SARA WILSON MARTIN
Credential	:	MA LMFTI LMFTA
Telephone Number	:	855-542-8255

Provider Enumeration Date	:	05/02/2015
Last Update Date	:	05/02/2015

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