Healthcare Provider Details

I. General information

NPI: 1316624604
Provider Name (Legal Business Name): SPENCER BRUCE BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16717 US HIGHWAY 17
HAMPSTEAD NC
28443-3696
US

IV. Provider business mailing address

1349 SPRING VALLEY RD
WILMINGTON NC
28405-1220
US

V. Phone/Fax

Practice location:
  • Phone: 910-599-2230
  • Fax:
Mailing address:
  • Phone: 919-599-8826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-66382
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: