Provider Demographics
NPI:1508569120
Name:HENN, SPENCER
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:HENN
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 1:18921 SW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5829
Mailing Address - Country:US
Mailing Address - Phone:513-348-7455
Mailing Address - Fax:
Practice Address - Street 1:18921 SW 30TH ST
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33029-5829
Practice Address - Country:US
Practice Address - Phone:513-348-7455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-263520106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-23-263520OtherBACB FLORIDA