Provider Demographics
NPI:1760141790
Name:SPENCER, VERNELLE LOUISE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:VERNELLE
Middle Name:LOUISE
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-5085
Mailing Address - Country:US
Mailing Address - Phone:701-334-6242
Mailing Address - Fax:
Practice Address - Street 1:3111 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-5085
Practice Address - Country:US
Practice Address - Phone:701-334-6242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1472475Medicaid