Provider Demographics
NPI:1518367655
Name:SPENCER, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
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 1:768 64TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-6608
Mailing Address - Country:US
Mailing Address - Phone:407-538-5284
Mailing Address - Fax:
Practice Address - Street 1:1000 W BROADWAY ST STE 214
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9262
Practice Address - Country:US
Practice Address - Phone:407-359-5693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13932235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013093200Medicaid