Provider Demographics
NPI:1114763372
Name:SPARK BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:SPARK BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-213-9989
Mailing Address - Street 1:12751 COUNTY ROAD 5 STE 109
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-2275
Mailing Address - Country:US
Mailing Address - Phone:952-213-9989
Mailing Address - Fax:
Practice Address - Street 1:12751 COUNTY ROAD 5 STE 109
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2275
Practice Address - Country:US
Practice Address - Phone:952-213-9989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-06
Last Update Date:2024-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency