Provider Demographics
NPI:1518650951
Name:LY, SPENCER RYAN
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:RYAN
Last Name:LY
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 1:16316 E CHERRY BLOSSOM LN
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-2359
Mailing Address - Country:US
Mailing Address - Phone:916-761-2854
Mailing Address - Fax:
Practice Address - Street 1:10786 LIVE OAK AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE CITY
Practice Address - State:CA
Practice Address - Zip Code:91780-2944
Practice Address - Country:US
Practice Address - Phone:626-447-3553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24975225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist