Provider Demographics
NPI:1346702248
Name:WHARTON, SPENCER (LPC INTERN)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:WHARTON
Suffix:
Gender:M
Credentials:LPC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HICKORY ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-1724
Mailing Address - Country:US
Mailing Address - Phone:541-760-2197
Mailing Address - Fax:833-224-2197
Practice Address - Street 1:110 HICKORY ST NW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1724
Practice Address - Country:US
Practice Address - Phone:541-760-2197
Practice Address - Fax:833-224-2197
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR5697101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR5697OtherPROFESSIONAL COUNSELOR INTERN