Provider Demographics
NPI:1659918621
Name:SPARKS, NICHOLAS ANDREW
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ANDREW
Last Name:SPARKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91150 COBURG INDUSTRIAL WAY
Mailing Address - Street 2:
Mailing Address - City:COBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97408
Mailing Address - Country:US
Mailing Address - Phone:541-687-1110
Mailing Address - Fax:
Practice Address - Street 1:91150COBURG INDUSTRIAL WAY
Practice Address - Street 2:
Practice Address - City:COBURG
Practice Address - State:OR
Practice Address - Zip Code:97408
Practice Address - Country:US
Practice Address - Phone:541-687-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-19-372101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)