Provider Demographics
NPI:1124503925
Name:SPENCER, LORETTA B (MS)
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:B
Last Name:SPENCER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:466 WAGNER TRL
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7036
Mailing Address - Country:US
Mailing Address - Phone:860-463-1955
Mailing Address - Fax:
Practice Address - Street 1:3937 SUNSET BLVD STE B
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-2423
Practice Address - Country:US
Practice Address - Phone:803-900-4890
Practice Address - Fax:803-931-3891
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC288562235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP8131Medicaid