Healthcare Provider Details

I. General information

NPI: 1134430705
Provider Name (Legal Business Name): MR. SPENCER LEE DEWOODY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 LATHAM ST APT 21
MOUNTAIN VIEW CA
94040-1601
US

IV. Provider business mailing address

2250 LATHAM STREET APT. 21
MOUNTAIN VIEW CA
94040
US

V. Phone/Fax

Practice location:
  • Phone: 559-392-1621
  • Fax:
Mailing address:
  • Phone: 559-392-1621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: