Provider Demographics
NPI:1487228110
Name:SPENCER, TRISTA TAELOR
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:TAELOR
Last Name:SPENCER
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 1:208 HASTINGS LN
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3324
Mailing Address - Country:US
Mailing Address - Phone:757-769-9595
Mailing Address - Fax:833-901-0451
Practice Address - Street 1:208 HASTINGS LN
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3324
Practice Address - Country:US
Practice Address - Phone:757-769-9595
Practice Address - Fax:833-901-0451
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-21-150091106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician