Provider Demographics
NPI:1437280419
Name:SPENCER, RICARDO P (LADAC)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:P
Last Name:SPENCER
Suffix:
Gender:M
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 REDROCK DR
Mailing Address - Street 2:PFS DEPT
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5683
Mailing Address - Country:US
Mailing Address - Phone:505-863-7000
Mailing Address - Fax:
Practice Address - Street 1:650 VANDEN BOSCH PKWY
Practice Address - Street 2:#B
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5508
Practice Address - Country:US
Practice Address - Phone:505-726-6900
Practice Address - Fax:505-722-6192
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3933101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMVNM00011N1OtherVALUE OPTIONS