Provider Demographics
NPI:1912442138
Name:WARDLOW, SPENCER T (MSED)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:T
Last Name:WARDLOW
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 N COLLEGE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3599
Mailing Address - Country:US
Mailing Address - Phone:812-803-0663
Mailing Address - Fax:812-213-8390
Practice Address - Street 1:804 N COLLEGE AVE STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3599
Practice Address - Country:US
Practice Address - Phone:812-803-0663
Practice Address - Fax:812-213-8390
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-23
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health