Basic Information
| Provider Information | |||||||||
| NPI: | 1093225807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | CHANIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 108 | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456380108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405321613 | ||||||||
| FaxNumber: | 7405321715 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405321613 | ||||||||
| FaxNumber: | 7405321715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2017 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | CDCA.163600 | OH | N | Other Service Providers | Case Manager/Care Coordinator | 104100000X | S.2207890 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0492997 | 05 | OH | MEDICAID |