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General NPI Number Information
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NPI Number | 1376359695
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Entity Type | Organization
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Legal Business Name | SPARK BEHAVIORAL HEALTH LLC
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Dates
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Enumeration Date | 12/10/2024
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Last Update Date | 08/05/2025
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Provider Practice Location Address
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Address Line | 11000 SW BARBUR BLVD STE 100
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City | PORTLAND
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State | OR
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Zip | 97219-8691
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Country | US
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Telephone | 971-228-9848
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Fax |
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Provider Business Mailing Address
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Address Line | 4550 SW BETTS AVE # 44
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City | BEAVERTON
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State | OR
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Zip | 97005-2869
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CO-CEO
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Name | TIMNIT YIKEALO
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Credential |
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Telephone | 971-228-9848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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