Provider Demographics
NPI:1295698603
Name:WILLIAMS, SPENCER KELLY
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:KELLY
Last Name:WILLIAMS
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 1:4852 W 118TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2063
Mailing Address - Country:US
Mailing Address - Phone:310-663-0018
Mailing Address - Fax:
Practice Address - Street 1:4852 W 118TH ST APT 1
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2063
Practice Address - Country:US
Practice Address - Phone:310-663-0018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-03
Last Update Date:2025-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94005225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist