Basic Information
| Provider Information | |||||||||
| NPI: | 1689792947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEDWELL | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | BROOKS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 SAN PEDRO DR SE | ||||||||
| Address2: | BUILDING 18 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1501 SAN PEDRO DR SE | ||||||||
| Address2: | BUILDING 18 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0103951 | NM | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | C-08275 | NM | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | M-07294 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.