Healthcare Provider Details

I. General information

NPI: 1578074126
Provider Name (Legal Business Name): SHERIDAN H SPENCER LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHERIDAN SPENCER LAC

II. Dates (important events)

Enumeration Date: 10/21/2017
Last Update Date: 10/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 THOMPSON BRIDGE RD STE 101
GAINESVILLE GA
30501-1780
US

IV. Provider business mailing address

1370 THOMPSON BRIDGE RD STE 101
GAINESVILLE GA
30501-1780
US

V. Phone/Fax

Practice location:
  • Phone: 855-438-5382
  • Fax:
Mailing address:
  • Phone: 855-438-5382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number410
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: