Provider Demographics
NPI:1013153253
Name:SPENCE, LARRY ANTHONY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:ANTHONY
Last Name:SPENCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5626 N 91ST ST STE 301
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-2745
Mailing Address - Country:US
Mailing Address - Phone:414-461-1088
Mailing Address - Fax:414-461-1049
Practice Address - Street 1:5626 N 91ST ST STE 301
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-2745
Practice Address - Country:US
Practice Address - Phone:414-461-1088
Practice Address - Fax:414-461-1049
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4152-120101YM0800X, 104100000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40921600Medicaid