Provider Demographics
NPI:1295570646
Name:SPENCER-WEISMAN, IDA G
Entity type:Individual
Prefix:DR
First Name:IDA
Middle Name:G
Last Name:SPENCER-WEISMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:IDA
Other - Middle Name:G
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:7190 W SUNSET BLVD STE 1041
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-4415
Mailing Address - Country:US
Mailing Address - Phone:310-600-1288
Mailing Address - Fax:
Practice Address - Street 1:1245 N LAUREL AVE APT 5
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-5135
Practice Address - Country:US
Practice Address - Phone:323-376-5023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111551106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist