Provider Demographics
NPI:1538211230
Name:SPENCER, THOMAS J (PSY D)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:SPENCER
Suffix:
Gender:M
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 1:2625 FAIRWAY DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-3936
Mailing Address - Country:US
Mailing Address - Phone:573-642-1775
Mailing Address - Fax:573-642-1850
Practice Address - Street 1:2625 FAIRWAY DR
Practice Address - Street 2:SUITE E
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-3936
Practice Address - Country:US
Practice Address - Phone:573-642-1775
Practice Address - Fax:573-642-1850
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003030098103T00000X, 103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498312305Medicaid