Basic Information
| Provider Information | |||||||||
| NPI: | 1164728697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | ROY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | LPC/S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3681 WINKLER AVENUE EXT | ||||||||
| Address2: | APT. 1017 BEACH CLUB | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339169468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342337361 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3033 WINKLER AVENUE EXT | ||||||||
| Address2: | VA OUTPATIENT CLINIC | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339169413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399393939 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2011 | ||||||||
| LastUpdateDate: | 02/01/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | #0640 | MS | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | #2603 | AL | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.