Provider Demographics
NPI:1992442636
Name:SPENCER, BRAXTON KENDALL
Entity type:Individual
Prefix:
First Name:BRAXTON
Middle Name:KENDALL
Last Name:SPENCER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27990 SHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92585-9155
Mailing Address - Country:US
Mailing Address - Phone:951-208-9135
Mailing Address - Fax:
Practice Address - Street 1:27990 SHERMAN RD
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92585-9155
Practice Address - Country:US
Practice Address - Phone:951-208-9135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-15
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst