Provider Demographics
NPI:1811203664
Name:SOUTHALL, SPENCE (PT)
Entity Type:Individual
Prefix:
First Name:SPENCE
Middle Name:
Last Name:SOUTHALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 COTTONWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-3033
Mailing Address - Country:US
Mailing Address - Phone:325-676-5633
Mailing Address - Fax:325-704-5471
Practice Address - Street 1:1633 COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601
Practice Address - Country:US
Practice Address - Phone:325-676-5633
Practice Address - Fax:325-704-5471
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1194608225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist