Basic Information
| Provider Information | |||||||||
| NPI: | 1659874881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | JULIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1434 E POPLAR ST | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832013168 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 465 MEMORIAL DR | ||||||||
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| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082344700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2018 | ||||||||
| LastUpdateDate: | 03/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.