Provider Demographics
NPI:1386226355
Name:SPENCER, BROOKE A (PTA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:SPENCER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12631 LAKE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-3931
Mailing Address - Country:US
Mailing Address - Phone:813-363-1148
Mailing Address - Fax:
Practice Address - Street 1:827 CYPRESS VILLAGE BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-6838
Practice Address - Country:US
Practice Address - Phone:813-633-0669
Practice Address - Fax:813-633-0881
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27737225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA27737OtherFL PTA LICENSE