Provider Demographics
NPI:1336151216
Name:SPENCER, EDWARD GEORGE JR (PHD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:GEORGE
Last Name:SPENCER
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6405 EL PATO CT
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-4309
Mailing Address - Country:US
Mailing Address - Phone:760-736-9161
Mailing Address - Fax:
Practice Address - Street 1:2945 HARDING ST
Practice Address - Street 2:STE 104
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1818
Practice Address - Country:US
Practice Address - Phone:760-736-9161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10491103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY104910Medicare ID - Type UnspecifiedMEDICARE
CACP10491Medicare UPIN