Provider Demographics
NPI:1881143014
Name:SPENCER, TAMMY (MS PSYCHOLOGY)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:MS PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 DANDELION LN
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4126
Mailing Address - Country:US
Mailing Address - Phone:912-484-9573
Mailing Address - Fax:833-790-2161
Practice Address - Street 1:2404 WISE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-5521
Practice Address - Country:US
Practice Address - Phone:843-365-8884
Practice Address - Fax:843-365-6697
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC13107292Medicaid