Healthcare Provider Details

I. General information

NPI: 1669094025
Provider Name (Legal Business Name): SPENCER CHARLES DAWSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 N WALNUT ST STE 905
BLOOMINGTON IN
47404-2008
US

IV. Provider business mailing address

2620 N WALNUT ST STE 905
BLOOMINGTON IN
47404-2008
US

V. Phone/Fax

Practice location:
  • Phone: 812-269-2433
  • Fax:
Mailing address:
  • Phone: 812-269-2433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20043352A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code173F00000X
TaxonomySleep Specialist (PhD)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: