Provider Demographics
NPI:1750486809
Name:SPENCER, WESLEY DANIEL
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:DANIEL
Last Name:SPENCER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:WESLEY
Other - Middle Name:DANIEL
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:405 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9471
Mailing Address - Country:US
Mailing Address - Phone:435-750-6118
Mailing Address - Fax:
Practice Address - Street 1:90 E 200 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4034
Practice Address - Country:US
Practice Address - Phone:435-752-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4803198-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870401386SP1OtherEMIA
UT70578OtherPEHP
UT107003178101OtherIHC PROVIDER NETWORK
UT870401386SP1OtherEMIA