Provider Demographics
NPI:1881189421
Name:SPENCER, KAWANZA (OWNER, REGISTEINTERN)
Entity Type:Individual
Prefix:
First Name:KAWANZA
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:OWNER, REGISTEINTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6888 PINE FOREST ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-2673
Mailing Address - Country:US
Mailing Address - Phone:850-972-9897
Mailing Address - Fax:850-972-9898
Practice Address - Street 1:6866 PINE FOREST RD STE A
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526-6903
Practice Address - Country:US
Practice Address - Phone:850-972-9897
Practice Address - Fax:850-972-9898
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1830101Y00000X, 101YM0800X, 101YP2500X, 103K00000X, 251C00000X
FL15681101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1841785482Medicaid
FL1881189421Medicaid
FL$$$$$$$$$Medicaid