Healthcare Provider Details

I. General information

NPI: 1881358901
Provider Name (Legal Business Name): SPARROW PROFESSIONAL DEVELOPMENT & COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 SE JEFFERSON ST
DALLAS OR
97338-2025
US

IV. Provider business mailing address

1151 SW LEVENS ST
DALLAS OR
97338-2266
US

V. Phone/Fax

Practice location:
  • Phone: 503-910-6822
  • Fax:
Mailing address:
  • Phone: 503-910-6822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: SLAD F THACKERAY
Title or Position: DIRECTOR/OWNER
Credential:
Phone: 503-910-6822