Healthcare Provider Details

I. General information

NPI: 1679612386
Provider Name (Legal Business Name): GARY L SPENCER BA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4620 17TH ST
SARASOTA FL
34235-1843
US

IV. Provider business mailing address

4620 17TH STREET
SARASOTA FL
34235
US

V. Phone/Fax

Practice location:
  • Phone: 941-371-8820
  • Fax: 941-377-3194
Mailing address:
  • Phone: 941-371-8820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: