Provider Demographics
NPI:1194249292
Name:SPENCER SCOTT PSYCHOLOGIST CORP
Entity type:Organization
Organization Name:SPENCER SCOTT PSYCHOLOGIST CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:SPENCER
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:323-999-1395
Mailing Address - Street 1:2500 BENNETT AVE
Mailing Address - Street 2:1405
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-7171
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2510 MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-3581
Practice Address - Country:US
Practice Address - Phone:323-999-1395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-31
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124548359Medicaid