Provider Demographics
NPI:1922401959
Name:SPENCER, SUSAN H (LMT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10790 W LA GRANGE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6264
Mailing Address - Country:US
Mailing Address - Phone:208-863-3364
Mailing Address - Fax:
Practice Address - Street 1:10790 W LA GRANGE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-6264
Practice Address - Country:US
Practice Address - Phone:208-863-3364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-05
Last Update Date:2014-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-852225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist