Provider Demographics
NPI:1417013657
Name:SPENCER, ROBERT STEWART (MSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:STEWART
Last Name:SPENCER
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 121
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480-0121
Mailing Address - Country:US
Mailing Address - Phone:860-342-5622
Mailing Address - Fax:860-342-5622
Practice Address - Street 1:769 NEWFIELD ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-1846
Practice Address - Country:US
Practice Address - Phone:860-342-5622
Practice Address - Fax:860-342-5622
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0008211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT821OtherLCSW STATE LICENSE NUMBER