1750301321 NPI number — MRS. KIMBERLY GILLISPIE SPENCER LPC

Table of content: MRS. KIMBERLY GILLISPIE SPENCER LPC (NPI 1750301321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750301321 NPI number — MRS. KIMBERLY GILLISPIE SPENCER LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPENCER
Provider First Name:
KIMBERLY
Provider Middle Name:
GILLISPIE
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:
1750301321
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751803
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28275-1803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
865 WESTLAKE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT AIRY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27030-2102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-719-6100
Provider Business Practice Location Address Fax Number:
336-719-2313
Provider Enumeration Date:
07/19/2006

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:  3825 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 3825 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6103096 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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