Provider Demographics
NPI:1043407489
Name:SPENCER, BETTY SHARON (LCSW)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:SHARON
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:B.
Other - Middle Name:SHARON
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1337
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:
Practice Address - Street 1:516 E NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:928-697-4189
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-23681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ060012Medicaid
AZHSZ045Medicare PIN