Healthcare Provider Details

I. General information

NPI: 1073562625
Provider Name (Legal Business Name): MICHAEL E SPENCER LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 W EAU GALLIE BLVD SUITE 200
MELBOURNE FL
32934-7213
US

IV. Provider business mailing address

4290 COREY RD
MALABAR FL
32950-4305
US

V. Phone/Fax

Practice location:
  • Phone: 321-752-3100
  • Fax: 321-752-3234
Mailing address:
  • Phone: 321-727-7325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 8302
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: