Provider Demographics
NPI:1720335722
Name:SPENCER, SARA MICHELLE
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MICHELLE
Last Name:SPENCER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 WESTHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-5739
Mailing Address - Country:US
Mailing Address - Phone:618-335-0124
Mailing Address - Fax:
Practice Address - Street 1:904 E. MLK DR.
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801
Practice Address - Country:US
Practice Address - Phone:618-533-1391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILS15279381673101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health