Healthcare Provider Details

I. General information

NPI: 1689792947
Provider Name (Legal Business Name): SPENCER BROOKS BEDWELL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE BUILDING 18
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE BUILDING 18
ALBUQUERQUE NM
87108
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 505-265-1711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0103951
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-08275
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-07294
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: