Provider Demographics
NPI:1649965591
Name:SPARKS, TINA REBECCA (LMHC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:REBECCA
Last Name:SPARKS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 SANTA ELENA RD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1307
Mailing Address - Country:US
Mailing Address - Phone:314-276-8728
Mailing Address - Fax:
Practice Address - Street 1:333 RIO RANCHO BLVD NE STE 200
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1458
Practice Address - Country:US
Practice Address - Phone:505-814-1460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2023-0074101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor