Healthcare Provider Details

I. General information

NPI: 1568914885
Provider Name (Legal Business Name): SPENCER SEIDMAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 DWIGHT WAY SUITE 201
BERKELEY CA
94704-2633
US

IV. Provider business mailing address

2006 DWIGHT WAY SUITE 201
BERKELEY CA
94704-2633
US

V. Phone/Fax

Practice location:
  • Phone: 510-984-3514
  • Fax: 415-681-6908
Mailing address:
  • Phone: 510-984-3514
  • Fax: 415-681-6908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17699
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: