Provider Demographics
NPI:1073247664
Name:SPECTRUM HOUSE INC
Entity Type:Organization
Organization Name:SPECTRUM HOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:STEVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-607-6910
Mailing Address - Street 1:9900 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-8124
Mailing Address - Country:US
Mailing Address - Phone:850-607-6910
Mailing Address - Fax:850-607-6932
Practice Address - Street 1:2431 CREIGHTON RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-7337
Practice Address - Country:US
Practice Address - Phone:850-607-6910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECTRUM HOUSE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty