Basic Information
| Provider Information | |||||||||
| NPI: | 1124298500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CASAC-T | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RODRIGUEZ-SPENCER | ||||||||
| OtherFirstName: | TODD | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 254 FRANKLIN STREET | ||||||||
| Address2: | LAKE SHORE BEHAVIORAL HEALTH | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168420440 | ||||||||
| FaxNumber: | 7168424069 | ||||||||
| Practice Location | |||||||||
| Address1: | 951 NIAGARA STREET | ||||||||
| Address2: | ADOLESCENT OUTPATIENT CHEMICAL DEPENDENCY PROGRAM | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168835344 | ||||||||
| FaxNumber: | 7168841758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2008 | ||||||||
| LastUpdateDate: | 03/03/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 20181 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 20181 | 01 | NY | CASAC-T | OTHER |