Provider Demographics
NPI:1891850772
Name:SPELLMAN, MICHAEL B (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:B
Last Name:SPELLMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 27TH ST W
Mailing Address - Street 2:SUITE 125
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-1768
Mailing Address - Country:US
Mailing Address - Phone:941-753-0064
Mailing Address - Fax:941-753-2977
Practice Address - Street 1:4835 27TH ST W
Practice Address - Street 2:SUITE 125
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-1768
Practice Address - Country:US
Practice Address - Phone:941-753-0064
Practice Address - Fax:941-753-2977
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 3794103TH0100X, 103TC0700X
FLPY3794103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75971Medicare UPIN