Provider Demographics
NPI:1376359695
Name:SPARK BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:SPARK BEHAVIORAL HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAMIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-482-2089
Mailing Address - Street 1:4550 SW BETTS AVE # 44
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2869
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 NW BETHANY BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-5208
Practice Address - Country:US
Practice Address - Phone:425-773-8313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-10
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center