Provider Demographics
NPI:1619460409
Name:SPENCER, SUSANNAH
Entity Type:Individual
Prefix:
First Name:SUSANNAH
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 1:2229 S CHESTER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-9546
Mailing Address - Country:US
Mailing Address - Phone:517-588-1057
Mailing Address - Fax:
Practice Address - Street 1:2229 S CHESTER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-9546
Practice Address - Country:US
Practice Address - Phone:517-588-1057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician