Provider Demographics
NPI:1275514580
Name:SPENCER, KRISTEN ERICKA (MPT, PRC)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:ERICKA
Last Name:SPENCER
Suffix:
Gender:F
Credentials:MPT, PRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3685 ROSEHAVEN WAY
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2260
Mailing Address - Country:US
Mailing Address - Phone:478-987-9697
Mailing Address - Fax:
Practice Address - Street 1:150 SATELLITE BLVD NW STE B
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2167
Practice Address - Country:US
Practice Address - Phone:478-987-9697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008313225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist