Provider Demographics
NPI:1508874140
Name:SPENCER, COLVILLE WASHINGTON (MS; CAP; RMHC)
Entity Type:Individual
Prefix:MR
First Name:COLVILLE
Middle Name:WASHINGTON
Last Name:SPENCER
Suffix:
Gender:M
Credentials:MS; CAP; RMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13618 PARK LAKE DR
Mailing Address - Street 2:SUITE. 101
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-3394
Mailing Address - Country:US
Mailing Address - Phone:813-241-5029
Mailing Address - Fax:
Practice Address - Street 1:4612 N 56TH ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-7123
Practice Address - Country:US
Practice Address - Phone:813-986-5966
Practice Address - Fax:813-986-9718
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL766767100104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766767100Medicaid