MEDICARE: EDWARD GEORGE SPENCER JR. PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TF0000X	Family Psychologist	PSY10491	CA

General Provider Information

NPI Number	:	1336151216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD GEORGE SPENCER JR. PHD

Provider Business Mailing Address
First Line	:	6405 EL PATO CT
Second Line	:
City	:	CARLSBAD
State	:	CA
Zip	:	92009-4309
Country	:	US
Telephone Number	:	760-736-9161
Fax Number	:

Provider Business Practice Location Address
First Line	:	2945 HARDING ST
Second Line	:	STE 104
City	:	CARLSBAD
State	:	CA
Zip	:	92008-1818
Country	:	US
Telephone Number	:	760-736-9161
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	05/01/2017

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