Provider Demographics
NPI:1043973407
Name:SPENCER, RAISSA G (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:RAISSA
Middle Name:G
Last Name:SPENCER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-529-9200
Mailing Address - Fax:414-529-9207
Practice Address - Street 1:9200 W LOOMIS RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8887
Practice Address - Country:US
Practice Address - Phone:414-529-9200
Practice Address - Fax:414-529-9207
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI710426225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100193554Medicaid