Provider Demographics
NPI:1730643214
Name:SPENCER, SUSAN DERIAN (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:DERIAN
Last Name:SPENCER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13142 N HUNTERS CIR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-2843
Mailing Address - Country:US
Mailing Address - Phone:512-584-0515
Mailing Address - Fax:
Practice Address - Street 1:13142 N HUNTERS CIR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-2843
Practice Address - Country:US
Practice Address - Phone:210-860-5478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1006682225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist