Provider Demographics
NPI:1538644646
Name:SPENCER, MISTY DAWN
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:SPENCER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:DAWN
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:710 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-6324
Mailing Address - Country:US
Mailing Address - Phone:217-525-1064
Mailing Address - Fax:217-525-1651
Practice Address - Street 1:340 W STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2061
Practice Address - Country:US
Practice Address - Phone:217-245-6126
Practice Address - Fax:217-245-4296
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490205841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical