Provider Demographics
NPI:1053003160
Name:SHUMATE, SPENCER JON
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:JON
Last Name:SHUMATE
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 1:4137 PIGOTT RD SW
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28470-5588
Mailing Address - Country:US
Mailing Address - Phone:336-590-2194
Mailing Address - Fax:
Practice Address - Street 1:10926 S TRYON ST STE E
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4154
Practice Address - Country:US
Practice Address - Phone:855-201-5498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician