Provider Demographics
NPI:1912395260
Name:SPENCER, ELEANOR
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:
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 1:668 E 1600 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:FLANAGAN
Mailing Address - State:IL
Mailing Address - Zip Code:61740-8908
Mailing Address - Country:US
Mailing Address - Phone:815-252-8214
Mailing Address - Fax:
Practice Address - Street 1:668 E 1600 NORTH RD
Practice Address - Street 2:
Practice Address - City:FLANAGAN
Practice Address - State:IL
Practice Address - Zip Code:61740-8908
Practice Address - Country:US
Practice Address - Phone:815-252-8214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer