Provider Demographics
NPI:1083498794
Name:SPENCER-STURDIVVANT, TYENNA
Entity Type:Individual
Prefix:
First Name:TYENNA
Middle Name:
Last Name:SPENCER-STURDIVVANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 MARKET ST APT 317
Mailing Address - Street 2:
Mailing Address - City:MANASSAS PARK
Mailing Address - State:VA
Mailing Address - Zip Code:20111-3210
Mailing Address - Country:US
Mailing Address - Phone:202-422-3354
Mailing Address - Fax:
Practice Address - Street 1:4000 GENESEE PL STE 101
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-8302
Practice Address - Country:US
Practice Address - Phone:571-659-0056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker