Provider Demographics
NPI:1164805784
Name:SPENCER, AMANDA BERNICE EYGES (PSYD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:BERNICE EYGES
Last Name:SPENCER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:BERNICE
Other - Last Name:EYGES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1900 S MCDOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5473
Mailing Address - Country:US
Mailing Address - Phone:707-699-6100
Mailing Address - Fax:
Practice Address - Street 1:1900 S MCDOWELL BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-5473
Practice Address - Country:US
Practice Address - Phone:707-699-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSB94025397103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8121Medicaid