Provider Demographics
NPI:1114523313
Name:SPENCER, KIMBERLY DANIELLE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DANIELLE
Last Name:SPENCER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DANIELLE
Other - Last Name:COX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6683
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:
Practice Address - Street 1:444 ATKINS BLVD
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:AR
Practice Address - Zip Code:72360-2110
Practice Address - Country:US
Practice Address - Phone:870-295-4050
Practice Address - Fax:870-295-4054
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AR26362-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator