Provider Demographics
NPI:1053361089
Name:SPENCER, CYNTHIA (DO)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:
Other - Last Name:AUGUSTINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:812 E JOLLY RD
Mailing Address - Street 2:STE 210
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-6818
Mailing Address - Country:US
Mailing Address - Phone:517-346-8410
Mailing Address - Fax:517-346-8291
Practice Address - Street 1:812 E JOLLY RD
Practice Address - Street 2:STE G14
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-6818
Practice Address - Country:US
Practice Address - Phone:517-346-8270
Practice Address - Fax:517-346-8291
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010129482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI113428929Medicaid
MI0C36007051Medicare ID - Type UnspecifiedMEDICARE