Provider Demographics
NPI:1861840837
Name:SPENCER, IAN (MFT)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:SPENCER
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1614 AVALON ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-1816
Mailing Address - Country:US
Mailing Address - Phone:310-600-2037
Mailing Address - Fax:
Practice Address - Street 1:2610 INDUSTRY WAY
Practice Address - Street 2:BLDG., #7
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-4283
Practice Address - Country:US
Practice Address - Phone:213-807-6515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF86857106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist