Provider Demographics
NPI:1407268667
Name:SPARKS, ED (RASI)
Entity Type:Individual
Prefix:
First Name:ED
Middle Name:
Last Name:SPARKS
Suffix:
Gender:M
Credentials:RASI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 ASPEN ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-2665
Mailing Address - Country:US
Mailing Address - Phone:530-662-5727
Mailing Address - Fax:530-668-1198
Practice Address - Street 1:435 ASPEN ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2665
Practice Address - Country:US
Practice Address - Phone:530-662-5727
Practice Address - Fax:530-668-1198
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)