Provider Demographics
NPI:1437211083
Name:SPENCER, SHANA LYNN (FAODP)
Entity Type:Individual
Prefix:MS
First Name:SHANA
Middle Name:LYNN
Last Name:SPENCER
Suffix:
Gender:F
Credentials:FAODP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8528 FRITH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MI
Mailing Address - Zip Code:48063-1300
Mailing Address - Country:US
Mailing Address - Phone:810-824-0604
Mailing Address - Fax:
Practice Address - Street 1:400 STODDARD RD.
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:MI
Practice Address - Zip Code:48027
Practice Address - Country:US
Practice Address - Phone:810-392-2167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIS152765564736101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)