Provider Demographics
NPI:1659929826
Name:SMITH, SPENCER W (PTA)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 JELINEK AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:SCHOFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54476-3525
Mailing Address - Country:US
Mailing Address - Phone:920-323-1163
Mailing Address - Fax:
Practice Address - Street 1:2400 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-6738
Practice Address - Country:US
Practice Address - Phone:715-848-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2957225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant