Provider Demographics
NPI:1457365058
Name:SPENCE, CHARLES B (LIMHP, LMHC, CDGC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:B
Last Name:SPENCE
Suffix:
Gender:M
Credentials:LIMHP, LMHC, CDGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12035 Q STREET
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-3542
Mailing Address - Country:US
Mailing Address - Phone:402-991-0611
Mailing Address - Fax:402-991-6228
Practice Address - Street 1:12035 Q STREET
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-3542
Practice Address - Country:US
Practice Address - Phone:402-991-0611
Practice Address - Fax:402-991-6228
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE914101YM0800X, 101YM0800X
IA00813101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-0785436-26Medicaid