Basic Information
| Provider Information | |||||||||
| NPI: | 1306397666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | SHIRLEY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 SHELTON MCMURPHEY BLVD | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974014928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414852711 | ||||||||
| FaxNumber: | 8889750250 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 HILYARD ST | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974018122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4582057080 | ||||||||
| FaxNumber: | 4582057089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2016 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | T-16-443 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | R3226 | OR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | C4647 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 500720361 | 05 | OR | MEDICAID | 500716902 | 05 | OR | MEDICAID |