Provider Demographics
NPI:1447633839
Name:SPARKS, SCOTTYE (LPCC)
Entity type:Individual
Prefix:
First Name:SCOTTYE
Middle Name:
Last Name:SPARKS
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1484
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-1484
Mailing Address - Country:US
Mailing Address - Phone:502-222-2389
Mailing Address - Fax:502-222-2927
Practice Address - Street 1:4414 OLD LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:BUCKNER
Practice Address - State:KY
Practice Address - Zip Code:40010-9547
Practice Address - Country:US
Practice Address - Phone:502-222-2389
Practice Address - Fax:502-222-2927
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
KY281849101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100879980Medicaid