Healthcare Provider Details

I. General information

NPI: 1487988713
Provider Name (Legal Business Name): THOMAS DARRELL SPENCER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 RODEO PARK DR W
SANTA FE NM
87505-6351
US

IV. Provider business mailing address

157 NINE MILE RD
SANTA FE NM
87508-8912
US

V. Phone/Fax

Practice location:
  • Phone: 505-986-9633
  • Fax: 505-820-1209
Mailing address:
  • Phone: 505-426-5750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0169161
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7453
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: