Healthcare Provider Details

I. General information

NPI: 1235618166
Provider Name (Legal Business Name): SPENCER MISTER LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15600 19 MILE RD
CLINTON TWP MI
48038-3502
US

IV. Provider business mailing address

15600 19 MILE RD
CLINTON TWP MI
48038-3502
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-8700
  • Fax:
Mailing address:
  • Phone: 248-303-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSC60735158
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC60735158
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801105513
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: