Provider Information for 1275994543
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SUSAN SPARKS LCSW
Sex: Female
NPI: 1275994543
Last Updated: 2016-03-15
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||||||
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| NPI | 1275994543 | ||||||||||||
| Enumeration Date | 2016-03-15 | ||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||
| Sole Proprietor | NO | ||||||||||||
| Status | Active | ||||||||||||
| Mailing Address | 97 EASTGATE DR WASHINGTON, IL 61571-9271 United States Phone: 800-773-1682 | Fax:309-713-2898 | ||||||||||||
| Primary Practice Address | 8500 N KNOXVILLE AVE PEORIA, IL 61615-2079 United States Phone: 800-773-1682 | Fax:309-713-2898 | ||||||||||||
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