Provider Demographics
NPI:1063563286
Name:SPENCER, MARA M (MPT)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:M
Last Name:SPENCER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:M
Other - Last Name:ROBICHAUD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPT
Mailing Address - Street 1:851 S 70TH ST
Mailing Address - Street 2:STE. 101
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3147
Mailing Address - Country:US
Mailing Address - Phone:414-777-5100
Mailing Address - Fax:414-777-5112
Practice Address - Street 1:14555 W NATIONAL AVE
Practice Address - Street 2:STE. 135
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4494
Practice Address - Country:US
Practice Address - Phone:262-827-3180
Practice Address - Fax:262-827-3180
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5696-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5696-024OtherSTATE LICENSE