Provider Demographics
NPI:1750301321
Name:SPENCER, KIMBERLY GILLISPIE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:GILLISPIE
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-1267
Mailing Address - Country:US
Mailing Address - Phone:336-786-4522
Mailing Address - Fax:336-786-3752
Practice Address - Street 1:100 N POINTE BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2266
Practice Address - Country:US
Practice Address - Phone:336-789-6267
Practice Address - Fax:336-786-4245
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3825101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103096Medicaid