Provider Demographics
NPI:1215422274
Name:SPENCER, BRYANTA L (LISW-S)
Entity type:Individual
Prefix:
First Name:BRYANTA
Middle Name:L
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12401 ROCKSIDE RD UNIT 25611
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-7331
Mailing Address - Country:US
Mailing Address - Phone:216-303-4196
Mailing Address - Fax:
Practice Address - Street 1:12808 THRAVES AVE
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-4432
Practice Address - Country:US
Practice Address - Phone:216-303-4196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.17005191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical