Healthcare Provider Details

I. General information

NPI: 1245178656
Provider Name (Legal Business Name): DANIEL JOSEPH SPENCER IV CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 E 4140 S APT 34
SALT LAKE CITY UT
84107-1720
US

IV. Provider business mailing address

475 E 4140 S APT 34
SALT LAKE CITY UT
84107-1720
US

V. Phone/Fax

Practice location:
  • Phone: 585-333-6384
  • Fax:
Mailing address:
  • Phone: 585-333-6384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAC8913
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: