Provider Demographics
NPI:1306429741
Name:SPENCE, TATIANNA
Entity type:Individual
Prefix:
First Name:TATIANNA
Middle Name:
Last Name:SPENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 BRAMLETT FOREST TRL
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-7287
Mailing Address - Country:US
Mailing Address - Phone:973-914-9494
Mailing Address - Fax:
Practice Address - Street 1:2387 HUNTCREST WAY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-8126
Practice Address - Country:US
Practice Address - Phone:678-648-7644
Practice Address - Fax:678-648-7479
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-179703106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst