Provider Demographics
NPI:1013283878
Name:SPENCER, MIOK
Entity Type:Individual
Prefix:
First Name:MIOK
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 1:2660 TOWNSGATE RD STE 740A
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-5704
Mailing Address - Country:US
Mailing Address - Phone:805-490-3477
Mailing Address - Fax:
Practice Address - Street 1:2660 TOWNSGATE RD STE 740A
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-5704
Practice Address - Country:US
Practice Address - Phone:805-490-3477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA225400000XOther225400000X REHABILITATION PRACTITIONER