Provider Demographics
NPI:1760956817
Name:SPENCER, MARIYA JEAN
Entity Type:Individual
Prefix:
First Name:MARIYA
Middle Name:JEAN
Last Name:SPENCER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12109 COUNTY ROAD 452
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:75771-7001
Mailing Address - Country:US
Mailing Address - Phone:903-805-9399
Mailing Address - Fax:
Practice Address - Street 1:12109 COUNTY ROAD 452
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-7001
Practice Address - Country:US
Practice Address - Phone:903-805-9399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2131473225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant