Provider Demographics
NPI:1780783852
Name:SPENCER, TEENA MELLYN (LCSW)
Entity type:Individual
Prefix:
First Name:TEENA
Middle Name:MELLYN
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:PEACE RIVER CENTER
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33831-1559
Mailing Address - Country:US
Mailing Address - Phone:863-519-0575
Mailing Address - Fax:863-519-0728
Practice Address - Street 1:1835 GILMORE AVE
Practice Address - Street 2:PEACE RIVER CENTER
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3017
Practice Address - Country:US
Practice Address - Phone:863-519-0575
Practice Address - Fax:863-582-9251
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW98371041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL759130600Medicaid
FL759130600Medicaid