Provider Demographics
NPI:1003894379
Name:SPENCER, STEPHEN REESE (PT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:REESE
Last Name:SPENCER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-1185
Mailing Address - Country:US
Mailing Address - Phone:801-942-3311
Mailing Address - Fax:801-942-5955
Practice Address - Street 1:5734 S 1475 E
Practice Address - Street 2:#300
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4596
Practice Address - Country:US
Practice Address - Phone:801-475-7628
Practice Address - Fax:801-475-7639
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106176-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000066813Medicare PIN