Provider Demographics
NPI:1114140985
Name:SPENCER, PETER G (PHD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:SPENCER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 LARKSPUR DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-3440
Mailing Address - Country:US
Mailing Address - Phone:413-256-6733
Mailing Address - Fax:413-253-4089
Practice Address - Street 1:48 N PLEASANT ST
Practice Address - Street 2:SUITE 202
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002-1738
Practice Address - Country:US
Practice Address - Phone:413-253-1766
Practice Address - Fax:413-253-4089
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4972103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA4972OtherSTATE LICENSE NUMBER
MD3529-9096OtherAPA MEMBERSHIP NO.
MAW04700Medicaid
MA41071OtherNAT. REGISTRY NUMBER
MD0522503OtherMASS HEALTH PROVIDER NO.