Provider Demographics
NPI:1376867614
Name:BLALOCK, SPENCER FIELDING (LCSW)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:FIELDING
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2413
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-2413
Mailing Address - Country:US
Mailing Address - Phone:601-480-5683
Mailing Address - Fax:
Practice Address - Street 1:2121 NORTH AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6428
Practice Address - Country:US
Practice Address - Phone:970-242-0731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC56931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I800182Medicare PIN