Provider Demographics
NPI:1518650951
Name:LY, SPENCER RYAN
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:RYAN
Last Name:LY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1561 E ONTARIO AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-6663
Mailing Address - Country:US
Mailing Address - Phone:951-407-9233
Mailing Address - Fax:
Practice Address - Street 1:1561 E ONTARIO AVE STE 101
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-6663
Practice Address - Country:US
Practice Address - Phone:951-407-9233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2024-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24975225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist