Provider Demographics
NPI:1083814644
Name:SPENCER, COLLEEN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 TEXAS AVE
Mailing Address - Street 2:P.O. BOX 4588
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77805-4588
Mailing Address - Country:US
Mailing Address - Phone:979-822-6467
Mailing Address - Fax:979-821-9448
Practice Address - Street 1:4500 BISSONNET ST STE 340
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-3009
Practice Address - Country:US
Practice Address - Phone:713-838-9050
Practice Address - Fax:713-838-9098
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1010494225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1010494OtherSTATE LICENSE
TX062908102Medicaid