Provider Demographics
NPI:1043957020
Name:KAUFMAN, SPENCER GRANT
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:GRANT
Last Name:KAUFMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 E COLLINS ST
Mailing Address - Street 2:
Mailing Address - City:DEPOE BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97341-1931
Mailing Address - Country:US
Mailing Address - Phone:503-798-3607
Mailing Address - Fax:
Practice Address - Street 1:1111 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-5235
Practice Address - Country:US
Practice Address - Phone:541-574-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach