Provider Demographics
NPI:1093559791
Name:BRISTO, SPENCER COLE
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:COLE
Last Name:BRISTO
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 1:5225 MAPLE AVE APT 5304
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-8460
Mailing Address - Country:US
Mailing Address - Phone:940-704-4393
Mailing Address - Fax:
Practice Address - Street 1:411 N WASHINGTON AVE STE 3900
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1713
Practice Address - Country:US
Practice Address - Phone:945-468-9007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3133554225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist