Healthcare Provider Details

I. General information

NPI: 1447154182
Provider Name (Legal Business Name): TISHAE SPENCE
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W FAIRBANKS AVE STE 211A
WINTER PARK FL
32789-4547
US

IV. Provider business mailing address

960 LAKEFRONT VILLAGE DR
CLERMONT FL
34711-3252
US

V. Phone/Fax

Practice location:
  • Phone: 407-951-5022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: