Provider Demographics
NPI:1154682714
Name:SPENCER, LEON EDWARD (EDD)
Entity Type:Individual
Prefix:DR
First Name:LEON
Middle Name:EDWARD
Last Name:SPENCER
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30461-6778
Mailing Address - Country:US
Mailing Address - Phone:912-604-4195
Mailing Address - Fax:
Practice Address - Street 1:13 S MULBERRY ST
Practice Address - Street 2:SUITE B
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-7176
Practice Address - Country:US
Practice Address - Phone:912-604-4195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002151101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional