1043301583 NPI number — MRS. TRACIE B SPENCER LPC

Table of content: MRS. TRACIE B SPENCER LPC (NPI 1043301583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043301583 NPI number — MRS. TRACIE B SPENCER LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPENCER
Provider First Name:
TRACIE
Provider Middle Name:
B
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043301583
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 STONE ROAD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
KILGORE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75662-5494
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-986-9114
Provider Business Mailing Address Fax Number:
903-988-0243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 STONE ROAD
Provider Second Line Business Practice Location Address:
SUITE 102 BEHAVIORAL EMOTIONAL COUNSELING SERVICES
Provider Business Practice Location Address City Name:
KILGORE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75662-5494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-986-9114
Provider Business Practice Location Address Fax Number:
903-988-0243
Provider Enumeration Date:
09/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  14797 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 124876 . This is a "CHIP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 822246 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".