Basic Information
| Provider Information | |||||||||
| NPI: | 1851520670 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | CHA'KE'SHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 863 | ||||||||
| Address2: | |||||||||
| City: | DOUGLASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301330863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046944668 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1050 SHILOH RD NW STE 316 | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301448100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782132194 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2009 | ||||||||
| LastUpdateDate: | 07/14/2009 | ||||||||
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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 | 101Y00000X | LPC004886 | GA | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | LPC004886 | GA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | LPC004886 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.