Basic Information
| Provider Information | |||||||||
| NPI: | 1639180060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | ROBIN | ||||||||
| MiddleName: | GAIL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JONES | ||||||||
| OtherFirstName: | ROBIN | ||||||||
| OtherMiddleName: | GAIL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 66 STONE ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076263455 | ||||||||
| FaxNumber: | 2076263612 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 STONE ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076263455 | ||||||||
| FaxNumber: | 2076263612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | CC2707 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 417110099 | 05 | ME | MEDICAID |