Provider Demographics
NPI:1104026038
Name:SPENCER, LESLIE WAHL (DPT)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:WAHL
Last Name:SPENCER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7841 W CENTER ST
Mailing Address - Street 2:APT 3
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4945
Mailing Address - Country:US
Mailing Address - Phone:414-258-8830
Mailing Address - Fax:
Practice Address - Street 1:4861 S 27TH ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2603
Practice Address - Country:US
Practice Address - Phone:414-325-3325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10878-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL830420022Medicare PIN
WI000783207Medicare PIN