Healthcare Provider Details

I. General information

NPI: 1871696831
Provider Name (Legal Business Name): SPENCER EMERY WEBB LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 E MAIN ST STE 3
SAINT ANTHONY ID
83445-1546
US

IV. Provider business mailing address

PO BOX 18
SAINT ANTHONY ID
83445-0018
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-4900
  • Fax: 208-624-4030
Mailing address:
  • Phone: 208-356-4900
  • Fax: 208-624-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-29533
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: