Provider Demographics
NPI:1114278652
Name:MACDONALD, SPENCER JAMES
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:JAMES
Last Name:MACDONALD
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 1:3700 CAMPUS DR STE 105
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2603
Mailing Address - Country:US
Mailing Address - Phone:949-929-0539
Mailing Address - Fax:
Practice Address - Street 1:3700 CAMPUS DR STE 105
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2603
Practice Address - Country:US
Practice Address - Phone:949-929-0539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-24
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA96998106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist