Provider Demographics
NPI:1083786990
Name:SPENCER, CAROL SUE (LCSW, ACSW)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:SUE
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LCSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 ALBRIGHT RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-4469
Mailing Address - Country:US
Mailing Address - Phone:765-455-1020
Mailing Address - Fax:765-455-1920
Practice Address - Street 1:315 S BERKLEY RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-5114
Practice Address - Country:US
Practice Address - Phone:765-457-9719
Practice Address - Fax:765-457-5991
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000454A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN351950697OtherEMPLOYER ID NUMBER