Provider Demographics
NPI:1417470717
Name:SPENCER-CANTON, BETHESDA
Entity Type:Individual
Prefix:
First Name:BETHESDA
Middle Name:
Last Name:SPENCER-CANTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOSHUA
Other - Middle Name:CHANDLER
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 12024
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-0024
Mailing Address - Country:US
Mailing Address - Phone:801-558-5242
Mailing Address - Fax:
Practice Address - Street 1:510 NW 10TH AVE # 15
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3364
Practice Address - Country:US
Practice Address - Phone:801-558-5242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORBAP-E-10228120374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty