Provider Demographics
NPI:1588712004
Name:SPURLOCK, MISTIE RENNE (LPCC)
Entity type:Individual
Prefix:MS
First Name:MISTIE
Middle Name:RENNE
Last Name:SPURLOCK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:MS
Other - First Name:MISTIE
Other - Middle Name:RENNE
Other - Last Name:SPURLOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCC
Mailing Address - Street 1:439 CANOE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-4677
Mailing Address - Country:US
Mailing Address - Phone:270-860-5064
Mailing Address - Fax:
Practice Address - Street 1:2816 VEACH RD
Practice Address - Street 2:SUITE B
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-6295
Practice Address - Country:US
Practice Address - Phone:270-860-5064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0829101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional