Provider Demographics
NPI:1699516179
Name:GONZALEZ, SPENCER KELLEN
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:KELLEN
Last Name:GONZALEZ
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 1:255 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-2609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:84 DORMITORY ROW WEST
Practice Address - Street 2:
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38677
Practice Address - Country:US
Practice Address - Phone:513-346-8947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer