Basic Information
| Provider Information | |||||||||
| NPI: | 1750301321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | GILLISPIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1267 | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270301267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367864522 | ||||||||
| FaxNumber: | 3367863752 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N POINTE BLVD | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270302266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367896267 | ||||||||
| FaxNumber: | 3367864245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 03/23/2016 | ||||||||
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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 | 101YP2500X | 3825 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 6103096 | 05 | NC | MEDICAID |