Provider Demographics
NPI:1508615907
Name:SPENCER, LAURA (RBT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 COTTAGE HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:HAHIRA
Mailing Address - State:GA
Mailing Address - Zip Code:31632-3179
Mailing Address - Country:US
Mailing Address - Phone:229-539-1322
Mailing Address - Fax:
Practice Address - Street 1:4110 COTTAGE HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:HAHIRA
Practice Address - State:GA
Practice Address - Zip Code:31632-3179
Practice Address - Country:US
Practice Address - Phone:229-539-1322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-24-325725106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician