Provider Demographics
NPI:1730288234
Name:SPENCE, CHERYL G (LCSW)
Entity type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:G
Last Name:SPENCE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5877 CENTRAL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-2920
Mailing Address - Country:US
Mailing Address - Phone:219-762-9995
Mailing Address - Fax:219-762-9995
Practice Address - Street 1:5877 CENTRAL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-2920
Practice Address - Country:US
Practice Address - Phone:219-762-9995
Practice Address - Fax:219-762-9995
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001836A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000354457Medicare UPIN
IN235369Medicare UPIN
IN220450Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER