Provider Demographics
NPI:1871613943
Name:SPANGLE, RANDALL P (CSAC, ICS)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:P
Last Name:SPANGLE
Suffix:
Gender:M
Credentials:CSAC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 18TH AVE W
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806
Mailing Address - Country:US
Mailing Address - Phone:715-682-8015
Mailing Address - Fax:
Practice Address - Street 1:502 MAIN ST W STE 305
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-1512
Practice Address - Country:US
Practice Address - Phone:715-682-5207
Practice Address - Fax:715-682-5209
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7044-135101YA0400X
WI72-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39317500Medicaid