1396182838 NPI number — SPARKMAN BEHAVIORAL HEALTH, P. C.

Table of content: (NPI 1396182838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396182838 NPI number — SPARKMAN BEHAVIORAL HEALTH, P. C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPARKMAN BEHAVIORAL HEALTH, P. C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396182838
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 571
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88202-0571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-559-8607
Provider Business Mailing Address Fax Number:
866-559-8607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
313 W COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88201-5804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-559-8607
Provider Business Practice Location Address Fax Number:
866-559-8607
Provider Enumeration Date:
05/23/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SPARKMAN
Authorized Official First Name:
LORETTA
Authorized Official Middle Name:
MARGARET
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
575-626-1493

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  CNP-02005 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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