Provider Demographics
NPI:1477176733
Name:SPENCER, DANIELLE (MHP)
Entity Type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 CARTER ST STE 10
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-3227
Mailing Address - Country:US
Mailing Address - Phone:318-336-4700
Mailing Address - Fax:318-336-4777
Practice Address - Street 1:1109 CARTER ST STE 10
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3227
Practice Address - Country:US
Practice Address - Phone:318-336-4700
Practice Address - Fax:318-336-4777
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC9430101Y00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA640897031Medicaid