Healthcare Provider Details

I. General information

NPI: 1093768756
Provider Name (Legal Business Name): DOROTHY ANN SPENNER LCPC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 S ACADEMY AVE
EAGLE ID
83616-6541
US

IV. Provider business mailing address

136 S ACADEMY AVE
EAGLE ID
83616-6541
US

V. Phone/Fax

Practice location:
  • Phone: 208-859-7256
  • Fax: 208-939-9110
Mailing address:
  • Phone: 208-859-7256
  • Fax: 208-939-9110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC-17
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT 2637
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: