Provider Demographics
NPI:1235238627
Name:SPENCER, ANNETTE C (PHD)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:C
Last Name:SPENCER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 HAYNES ST
Mailing Address - Street 2:STE 345
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6703
Mailing Address - Country:US
Mailing Address - Phone:248-885-2956
Mailing Address - Fax:248-481-2172
Practice Address - Street 1:999 HAYNES ST
Practice Address - Street 2:STE 345
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6703
Practice Address - Country:US
Practice Address - Phone:248-593-5557
Practice Address - Fax:248-594-7313
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009811103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11289458OtherCAQH
MIP10912Medicare UPIN
11289458OtherCAQH