Provider Demographics
NPI:1235957937
Name:IACOLUCCI, SPENCER
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:IACOLUCCI
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 1:828 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4003
Mailing Address - Country:US
Mailing Address - Phone:509-593-8122
Mailing Address - Fax:509-769-5221
Practice Address - Street 1:828 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4003
Practice Address - Country:US
Practice Address - Phone:509-593-8122
Practice Address - Fax:509-769-5221
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61591363101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health