Provider Demographics
NPI:1699445601
Name:STOTT, SPENCER DAVID (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:DAVID
Last Name:STOTT
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10312 E REVOLUTION DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-7842
Mailing Address - Country:US
Mailing Address - Phone:480-309-3668
Mailing Address - Fax:
Practice Address - Street 1:275 E RIVULON BLVD STE 201
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0008
Practice Address - Country:US
Practice Address - Phone:702-483-5029
Practice Address - Fax:702-589-4872
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ264403363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health