Provider Demographics
NPI:1316141377
Name:WARE SPENCER, NICOLE ANTOINETTE (PSY D)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANTOINETTE
Last Name:WARE SPENCER
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1461
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30085-1461
Mailing Address - Country:US
Mailing Address - Phone:470-810-7811
Mailing Address - Fax:
Practice Address - Street 1:4325 1ST AVE # 1461
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4498
Practice Address - Country:US
Practice Address - Phone:678-404-1077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013431103T00000X
GAPSY004171103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist