Provider Demographics
NPI:1922533793
Name:SPENCER, TANILLE MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:TANILLE
Middle Name:MARIE
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 1:2550 CONNER AVE
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-1024
Mailing Address - Country:US
Mailing Address - Phone:304-437-0690
Mailing Address - Fax:
Practice Address - Street 1:89 OLDE MAIN PLZ
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2707
Practice Address - Country:US
Practice Address - Phone:304-437-0690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2015-3329225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist