Provider Demographics
NPI:1568055549
Name:SPELLER, RICKY A JR
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:A
Last Name:SPELLER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 YARBOROUGH DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-2748
Mailing Address - Country:US
Mailing Address - Phone:919-612-3481
Mailing Address - Fax:
Practice Address - Street 1:4680 BROWNSBORO RD RM A2
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3428
Practice Address - Country:US
Practice Address - Phone:814-218-2598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCAL6322101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor