Basic Information
| Provider Information | |||||||||
| NPI: | 1730367616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPARKS | ||||||||
| FirstName: | EBONIE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 448 LAKESHORE PKWY | ||||||||
| Address2: | STE 110 | ||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297304264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033293177 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1807 E INNES ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281466030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046333616 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2008 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P004086 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.