Provider Demographics
NPI:1588395123
Name:SPENCER-HUBER, MARY (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SPENCER-HUBER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 FAIR OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76210-8872
Mailing Address - Country:US
Mailing Address - Phone:518-496-2043
Mailing Address - Fax:
Practice Address - Street 1:2000 FAIR OAKS CIR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:TX
Practice Address - Zip Code:76210-8872
Practice Address - Country:US
Practice Address - Phone:518-496-2043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2296103K00000X
TX38346103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst