Provider Demographics
NPI:1700109071
Name:SPENCER, CASSIDY (DC)
Entity Type:Individual
Prefix:MRS
First Name:CASSIDY
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MRS
Other - First Name:CASSIDY
Other - Middle Name:
Other - Last Name:MIRANDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:2707 E FREMONT ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-3936
Mailing Address - Country:US
Mailing Address - Phone:209-333-3833
Mailing Address - Fax:209-369-4839
Practice Address - Street 1:2707 E FREMONT ST
Practice Address - Street 2:SUITE 6
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-3936
Practice Address - Country:US
Practice Address - Phone:209-333-3833
Practice Address - Fax:209-369-4839
Is Sole Proprietor?:No
Enumeration Date:2010-03-01
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 29367111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor