Provider Demographics
NPI:1417437070
Name:SPOONMORE, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:SPOONMORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 6TH STREET FRONTAGE RD E
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-5735
Mailing Address - Country:US
Mailing Address - Phone:217-525-8332
Mailing Address - Fax:
Practice Address - Street 1:5220 6TH STREET FRONTAGE RD E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5735
Practice Address - Country:US
Practice Address - Phone:217-525-8332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician