MEDICARE: DAVID E SPENCER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1669705414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID E SPENCER LCSW

Provider Business Mailing Address
First Line	:	1904 JENNIE LEE DR
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6159
Country	:	US
Telephone Number	:	208-520-7074
Fax Number	:	208-970-6188

Provider Business Practice Location Address
First Line	:	1904 JENNIE LEE DR
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6159
Country	:	US
Telephone Number	:	208-520-7074
Fax Number	:	208-970-6188

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2009
Last Update Date	:	01/12/2023

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Directions to “ DAVID E SPENCER LCSW” Practice Location

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