Healthcare Provider Details

I. General information

NPI: 1730639865
Provider Name (Legal Business Name): EILAKEISHA BEVERLY ANN SPENCER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 GRANITE AVE STE 260
MILTON MA
02186-4381
US

IV. Provider business mailing address

520 DUDLEY ST
ROXBURY MA
02119-2769
US

V. Phone/Fax

Practice location:
  • Phone: 857-203-7001
  • Fax: 857-588-7708
Mailing address:
  • Phone: 617-543-9208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: