Provider Demographics
NPI:1578074126
Name:SPENCER, SHERIDAN H (LAC)
Entity Type:Individual
Prefix:
First Name:SHERIDAN
Middle Name:H
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:SHERIDAN
Other - Middle Name:
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:1370 THOMPSON BRIDGE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-1780
Mailing Address - Country:US
Mailing Address - Phone:855-438-5382
Mailing Address - Fax:
Practice Address - Street 1:1370 THOMPSON BRIDGE RD STE 101
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-1780
Practice Address - Country:US
Practice Address - Phone:855-438-5382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-21
Last Update Date:2017-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA410171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist