Provider Demographics
NPI:1740743459
Name:SPENCER, NICHOLAS (OTR/L)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:SPENCER
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 9 BOX 1102
Mailing Address - Street 2:
Mailing Address - City:GATEWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63942-9034
Mailing Address - Country:US
Mailing Address - Phone:573-255-3347
Mailing Address - Fax:
Practice Address - Street 1:RR 9 BOX 1102
Practice Address - Street 2:
Practice Address - City:GATEWOOD
Practice Address - State:MO
Practice Address - Zip Code:63942-9034
Practice Address - Country:US
Practice Address - Phone:573-255-3347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018031484320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities