Provider Demographics
NPI:1942639422
Name:SPENCER, RENA
Entity Type:Individual
Prefix:
First Name:RENA
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 1:5208 LIBERTY DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-9737
Mailing Address - Country:US
Mailing Address - Phone:231-357-4515
Mailing Address - Fax:
Practice Address - Street 1:5208 LIBERTY DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49685-9737
Practice Address - Country:US
Practice Address - Phone:231-357-4515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001694235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist