Provider Demographics
NPI:1639399678
Name:SPENCER, PAMELA JEAN (EDD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:JEAN
Last Name:SPENCER
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 GIFFARD WAY
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2310
Mailing Address - Country:US
Mailing Address - Phone:631-367-9256
Mailing Address - Fax:631-367-6655
Practice Address - Street 1:3 GIFFARD WAY
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-2310
Practice Address - Country:US
Practice Address - Phone:631-367-9256
Practice Address - Fax:631-367-2878
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005787-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist