Healthcare Provider Details

I. General information

NPI: 1285899716
Provider Name (Legal Business Name): JUDITH K SPENCER SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 WINDY HILL DR
LAFAYETTE IN
47905-2862
US

IV. Provider business mailing address

2003 TRACE 20
WEST LAFAYETTE IN
47906-1885
US

V. Phone/Fax

Practice location:
  • Phone: 765-477-7791
  • Fax: 765-474-2986
Mailing address:
  • Phone: 765-497-0540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22004390A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: