Provider Demographics
NPI:1356464655
Name:SPARKS, RODNEY LEE (BSW)
Entity Type:Individual
Prefix:MR
First Name:RODNEY
Middle Name:LEE
Last Name:SPARKS
Suffix:
Gender:M
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1399 W 3600 S
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-4107
Mailing Address - Country:US
Mailing Address - Phone:208-356-0954
Mailing Address - Fax:
Practice Address - Street 1:218 DIVIDEND DR STE 3
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-3510
Practice Address - Country:US
Practice Address - Phone:208-359-9683
Practice Address - Fax:208-359-9683
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-2558104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker