Provider Demographics
NPI:1023567195
Name:SPENCER, CAROL (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:SPENCER
Other - Last Name:MONGEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:175 SAMARITAN DR
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-1964
Mailing Address - Country:US
Mailing Address - Phone:706-253-4673
Mailing Address - Fax:706-253-4679
Practice Address - Street 1:3905 GRISSOM PKWY
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32926-3669
Practice Address - Country:US
Practice Address - Phone:321-637-1866
Practice Address - Fax:321-634-3539
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL137171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical