Provider Demographics
NPI:1215701552
Name:SPISAK, MONICA ELAINE
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:ELAINE
Last Name:SPISAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12330 SE BUSH ST APT 51
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3480
Mailing Address - Country:US
Mailing Address - Phone:503-860-9812
Mailing Address - Fax:
Practice Address - Street 1:16022 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-3528
Practice Address - Country:US
Practice Address - Phone:503-860-9812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist