Provider Demographics
NPI:1801459417
Name:MATTOX, SPENCER J'CARDALE
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:J'CARDALE
Last Name:MATTOX
Suffix:
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 1:1690 PETAL DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-6932
Mailing Address - Country:US
Mailing Address - Phone:619-252-2336
Mailing Address - Fax:
Practice Address - Street 1:601 TELEGRAPH CANYON RD APT 355
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-6588
Practice Address - Country:US
Practice Address - Phone:619-252-2336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA172V00000X
CA144309106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker