Provider Demographics
NPI:1902815202
Name:SPENCER, PHILLIP BRIAN (MSCCC/SLP)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:BRIAN
Last Name:SPENCER
Suffix:
Gender:M
Credentials:MSCCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79101-4140
Mailing Address - Country:US
Mailing Address - Phone:806-337-5016
Mailing Address - Fax:806-337-5015
Practice Address - Street 1:400 W 14TH AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79101-4140
Practice Address - Country:US
Practice Address - Phone:806-337-5016
Practice Address - Fax:806-337-5015
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101754235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T4286;8T4074OtherBCBS
TX175217201Medicaid