1811339039 NPI number — MRS. EMILY ROSE SPARKS MSW, LICSW

Table of content: MRS. EMILY ROSE SPARKS MSW, LICSW (NPI 1811339039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811339039 NPI number — MRS. EMILY ROSE SPARKS MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPARKS
Provider First Name:
EMILY
Provider Middle Name:
ROSE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MENART
Provider Other First Name:
EMILY
Provider Other Middle Name:
ROSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW, LICSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1811339039
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 FRUIT ST.
Provider Second Line Business Mailing Address:
WAC 817
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
857-331-3431
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 FRUIT ST.
Provider Second Line Business Practice Location Address:
WAC 817
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
857-331-3431
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 120684 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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