Healthcare Provider Details

I. General information

NPI: 1972952463
Provider Name (Legal Business Name): MICHELLE SPADER, PSYD, BCBA-D, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6260 S SUNBURY RD SUITE 5
WESTERVILLE OH
43081-9002
US

IV. Provider business mailing address

6260 S SUNBURY RD SUITE 5
WESTERVILLE OH
43081-9002
US

V. Phone/Fax

Practice location:
  • Phone: 614-852-4152
  • Fax: 614-852-4151
Mailing address:
  • Phone: 614-852-4152
  • Fax: 614-852-4151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6516
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number6516
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6516
License Number StateOH

VIII. Authorized Official

Name: DR. MICHELLE SPADER
Title or Position: PSYCHOLOGIST/FOUNDER
Credential: PSYD, BCBA-D
Phone: 614-852-4152