Provider Demographics
NPI: | 1164805784 |
---|---|
Name: | SPENCER, AMANDA BERNICE EYGES (PSYD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | AMANDA |
Middle Name: | BERNICE EYGES |
Last Name: | SPENCER |
Suffix: | |
Gender: | F |
Credentials: | PSYD |
Other - Prefix: | MS |
Other - First Name: | AMANDA |
Other - Middle Name: | BERNICE |
Other - Last Name: | EYGES |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | MA |
Mailing Address - Street 1: | 1900 S MCDOWELL BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | PETALUMA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 94954-5473 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 707-699-6100 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1900 S MCDOWELL BLVD |
Practice Address - Street 2: | |
Practice Address - City: | PETALUMA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 94954-5473 |
Practice Address - Country: | US |
Practice Address - Phone: | 707-699-6100 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2015-07-01 |
Last Update Date: | 2022-01-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
390200000X | ||
CA | PSB94025397 | 103TC0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 8121 | Medicaid |