Provider Demographics
NPI:1568538429
Name:ROEBUCK SPENCER, TRESA (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRESA
Middle Name:
Last Name:ROEBUCK SPENCER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 UNIVERSITY BLVD S
Mailing Address - Street 2:ATTN: URSULA SHERAN
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216
Mailing Address - Country:US
Mailing Address - Phone:904-345-7640
Mailing Address - Fax:
Practice Address - Street 1:1317 BAY BRIDGE CT
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-7076
Practice Address - Country:US
Practice Address - Phone:405-325-7467
Practice Address - Fax:405-325-2523
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9767103TC0700X
DCPSY1000189103G00000X, 103TC0700X
VA0810003608103G00000X, 103TC0700X
OK1078103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCH360-0017OtherBCBS
DC016612N53Medicare PIN
Q38672Medicare UPIN