Provider Demographics
NPI:1417336801
Name:SPENNER, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SPENNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N BENJAMIN LN STE 201
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5094
Mailing Address - Country:US
Mailing Address - Phone:208-287-5620
Mailing Address - Fax:208-287-5609
Practice Address - Street 1:400 N BENJAMIN LN STE 201
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5094
Practice Address - Country:US
Practice Address - Phone:208-287-5620
Practice Address - Fax:208-287-5609
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5617101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional