Healthcare Provider Details

I. General information

NPI: 1710227236
Provider Name (Legal Business Name): KELLY SPOONOGLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 FRANKLIN ST
SCHENECTADY NY
12305-2107
US

IV. Provider business mailing address

PO BOX 417153
BOSTON MA
02241-7153
US

V. Phone/Fax

Practice location:
  • Phone: 518-372-7031
  • Fax: 518-372-7064
Mailing address:
  • Phone: 518-952-8140
  • Fax: 518-952-8287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: