=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144715491
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEGRA SPENCER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2018
-----------------------------------------------------
Last Update Date | 09/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17637 SHURMER RD
-----------------------------------------------------
City | STRONGSVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44136-6157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-210-4041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1949 GREEN RD
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44121-1160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | S1600489
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I.2203695
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------