Provider Demographics
NPI:1265207096
Name:GRIFFIN, SPENCER (LMSW)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4737 S AFTON PL STE A
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2317
Mailing Address - Country:US
Mailing Address - Phone:208-417-0623
Mailing Address - Fax:208-417-0641
Practice Address - Street 1:1051 BUCKBOARD TRL APT 1
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-3084
Practice Address - Country:US
Practice Address - Phone:208-389-8685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-43554104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker