Healthcare Provider Details

I. General information

NPI: 1306397666
Provider Name (Legal Business Name): SHIRLEY ANN SPENCER M.A., QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HILYARD ST
EUGENE OR
97401-8122
US

IV. Provider business mailing address

10 SHELTON MCMURPHEY BLVD
EUGENE OR
97401-4928
US

V. Phone/Fax

Practice location:
  • Phone: 458-205-7080
  • Fax: 458-205-7089
Mailing address:
  • Phone: 541-485-2711
  • Fax: 888-975-0250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-16-443
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR3226
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC4647
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500720361
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier500716902
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: