Provider Demographics
NPI:1134586605
Name:SPENCE, EARL JR (MED, MCAP)
Entity type:Individual
Prefix:MR
First Name:EARL
Middle Name:
Last Name:SPENCE
Suffix:JR
Gender:M
Credentials:MED, MCAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 LAKE WORTH RD.
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461
Mailing Address - Country:US
Mailing Address - Phone:561-439-8440
Mailing Address - Fax:
Practice Address - Street 1:1355 LAKE WORTH RD.
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461
Practice Address - Country:US
Practice Address - Phone:561-439-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251S00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101YA0400XMedicaid