Healthcare Provider Details

I. General information

NPI: 1073814968
Provider Name (Legal Business Name): T SPENCE M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 04/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 INTERNATIONAL PKWY STE 300
LAKE MARY FL
32746-5065
US

IV. Provider business mailing address

400 INTERNATIONAL PARKWAY SUITE 300
LAKE MARY FL
32746
US

V. Phone/Fax

Practice location:
  • Phone: 800-806-6026
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number106333
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA 10691
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: